Basic Information
Provider Information | |||||||||
NPI: | 1528578978 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LIEBERMAN | ||||||||
FirstName: | ALEX | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | BA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 31344 VIA COLINAS STE 108 | ||||||||
Address2: |   | ||||||||
City: | WESTLAKE VILLAGE | ||||||||
State: | CA | ||||||||
PostalCode: | 913626797 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8053793212 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 31344 VIA COLINAS STE 108 | ||||||||
Address2: |   | ||||||||
City: | WESTLAKE VILLAGE | ||||||||
State: | CA | ||||||||
PostalCode: | 913626797 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8053793212 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/11/2017 | ||||||||
LastUpdateDate: | 10/11/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |   |
ID Information
ID | Type | State | Issuer | Description | 45-3589857 | 01 |   | THE HOLMAN GROUP | OTHER |