Basic Information
| Provider Information | |||||||||
| NPI: | 1801945811 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIEBERKNECHT | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | SUSAN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PSYCHOLOGICAL ASSIST | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LIEBERKNECHT | ||||||||
| OtherFirstName: | REBECCA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CLINICAL TRAINEE | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3075 ADELINE ST. | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5108481112 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3075 ADELINE ST. | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5108481112 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2007 | ||||||||
| LastUpdateDate: | 11/15/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | PSB35555 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.