Provider Demographics
NPI:1891184396
Name:LIEDBERG MIRON, ANNA (MA, LLPC, NCC)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:LIEDBERG MIRON
Suffix:
Gender:F
Credentials:MA, LLPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1460 PROSPECT PL
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49006-3110
Mailing Address - Country:US
Mailing Address - Phone:269-381-8191
Mailing Address - Fax:
Practice Address - Street 1:1460 PROSPECT PL
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49006-3110
Practice Address - Country:US
Practice Address - Phone:269-381-8191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-21
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401014571101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health