Provider Demographics
NPI:1952541161
Name:LIEBERMAN, EDWARD LEWIS
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:LEWIS
Last Name:LIEBERMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 TAYLOR AVE
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:VT
Mailing Address - Zip Code:05443-1012
Mailing Address - Country:US
Mailing Address - Phone:802-453-5884
Mailing Address - Fax:
Practice Address - Street 1:89 MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:VT
Practice Address - Zip Code:05753-1459
Practice Address - Country:US
Practice Address - Phone:802-388-6751
Practice Address - Fax:802-388-3108
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-27
Last Update Date:2009-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT000440101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT000440OtherL.A.D.C.