1396984548 NPI number — DR. BETHANY A. LIEBERMAN PSY.D.

Table of content: MELISSA CHERYL KILGORE FNP-C (NPI 1164881454)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396984548 NPI number — DR. BETHANY A. LIEBERMAN PSY.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LIEBERMAN
Provider First Name:
BETHANY
Provider Middle Name:
A.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSY.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396984548
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/11/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
86 LAKE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURLINGTON
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05401-5297
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-865-3450
Provider Business Mailing Address Fax Number:
802-860-5011

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15 PINECREST DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ESSEX JUNCTION
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05452-2912
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-288-1087
Provider Business Practice Location Address Fax Number:
802-878-4404
Provider Enumeration Date:
02/11/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  0480000920 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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