Provider Demographics
NPI:1831426162
Name:LEWIS R. LIEBERMAN, INCORPORATED
Entity type:Organization
Organization Name:LEWIS R. LIEBERMAN, INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY/TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:LEWIS
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:LIEBERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PH D
Authorized Official - Phone:706-561-4625
Mailing Address - Street 1:5701 SHERBORNE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-4740
Mailing Address - Country:US
Mailing Address - Phone:706-561-4625
Mailing Address - Fax:
Practice Address - Street 1:1501 13TH ST
Practice Address - Street 2:SUITE J
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-2383
Practice Address - Country:US
Practice Address - Phone:706-315-1862
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-06
Last Update Date:2009-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA205103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000052401BMedicaid