Provider Demographics
NPI:1184903593
Name:LIEBERMAN, MICAH J (DC)
Entity type:Individual
Prefix:
First Name:MICAH
Middle Name:J
Last Name:LIEBERMAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13642 RIVERWAY DR
Mailing Address - Street 2:UNIT C
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-2656
Mailing Address - Country:US
Mailing Address - Phone:908-938-8323
Mailing Address - Fax:
Practice Address - Street 1:13642 RIVERWAY DR
Practice Address - Street 2:UNIT C
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-2656
Practice Address - Country:US
Practice Address - Phone:908-938-8323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-16
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011026323111N00000X
NJ38MC00695400111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor