Provider Demographics
NPI:1235957135
Name:LIEBMAN, NICOLE SAMANTHA
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:SAMANTHA
Last Name:LIEBMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 ELMIRA ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-4139
Mailing Address - Country:US
Mailing Address - Phone:718-619-9772
Mailing Address - Fax:
Practice Address - Street 1:1317 AVENUE J FL 2
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-3605
Practice Address - Country:US
Practice Address - Phone:718-814-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-30
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst