Provider Demographics
NPI:1902373384
Name:LIEBERMAN, DAVID BRUCE (BA, MS, CAS)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:BRUCE
Last Name:LIEBERMAN
Suffix:
Gender:M
Credentials:BA, MS, CAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 FOX HOLLOW LN
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-1142
Mailing Address - Country:US
Mailing Address - Phone:518-745-1120
Mailing Address - Fax:
Practice Address - Street 1:2 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-1702
Practice Address - Country:US
Practice Address - Phone:518-926-2050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-24
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00314998Medicaid