Provider Demographics
NPI:1972898203
Name:LIEBERMAN, JOHANNA OMARK (RD)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:OMARK
Last Name:LIEBERMAN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:JOHANNA
Other - Middle Name:MARIE
Other - Last Name:OMARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:3415 BAINBRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-2403
Mailing Address - Country:US
Mailing Address - Phone:718-741-2396
Mailing Address - Fax:718-920-6506
Practice Address - Street 1:3415 BAINBRIDGE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2403
Practice Address - Country:US
Practice Address - Phone:718-741-2396
Practice Address - Fax:718-920-6506
Is Sole Proprietor?:No
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic