Basic Information
| Provider Information | |||||||||
| NPI: | 1417461872 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LIEB | ||||||||
| FirstName: | LAUREN | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2532 N 124TH ST APT 251 | ||||||||
| Address2: | |||||||||
| City: | WAUWATOSA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532261030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622273639 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7322 W RAWSON AVE | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531328117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144339010 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2017 | ||||||||
| LastUpdateDate: | 04/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 59804 | TX | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 9159-123 | WI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1417461872 | 05 | WI | MEDICAID |