Provider Demographics
NPI:1770677809
Name:LIEBLER, ETHAN JOHN (MSPT)
Entity Type:Individual
Prefix:MR
First Name:ETHAN
Middle Name:JOHN
Last Name:LIEBLER
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 HEMLOCK DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735-2929
Mailing Address - Country:US
Mailing Address - Phone:516-852-5429
Mailing Address - Fax:516-293-3829
Practice Address - Street 1:600 NORTHERN BLVD
Practice Address - Street 2:117
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5200
Practice Address - Country:US
Practice Address - Phone:516-478-0014
Practice Address - Fax:516-487-3989
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22696225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04776Medicare ID - Type UnspecifiedQUEENS GHI
NYQL5051Medicare ID - Type UnspecifiedNASSAU