Basic Information
| Provider Information | |||||||||
| NPI: | 1902373384 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LIEBERMAN | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | BRUCE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | BA, MS, CAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 44 FOX HOLLOW LN | ||||||||
| Address2: | |||||||||
| City: | QUEENSBURY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128041142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187451120 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2 COUNTRY CLUB RD | ||||||||
| Address2: | |||||||||
| City: | QUEENSBURY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128041702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5189262050 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2018 | ||||||||
| LastUpdateDate: | 10/24/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TS0200X | NY | Y | Behavioral Health & Social Service Providers | Psychologist | School |
ID Information
| ID | Type | State | Issuer | Description | 00314998 | 05 | NY | MEDICAID |