Provider Demographics
NPI:1740681519
Name:LIVE LOVE AND GROWTH
Entity type:Organization
Organization Name:LIVE LOVE AND GROWTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LIEBERENZ
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:331-250-1586
Mailing Address - Street 1:592 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-2205
Mailing Address - Country:US
Mailing Address - Phone:331-250-1586
Mailing Address - Fax:
Practice Address - Street 1:1010 JORIE BLVD
Practice Address - Street 2:SUITE 112
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523-2215
Practice Address - Country:US
Practice Address - Phone:331-250-1586
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-10
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.009005101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL101Y00000XOtherPRIVATE INSURANCE