1801945811 NPI number — REBECCA SUSAN LIEBERKNECHT PSYCHOLOGICAL ASSIST

Table of content: REBECCA SUSAN LIEBERKNECHT PSYCHOLOGICAL ASSIST (NPI 1801945811)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801945811 NPI number — REBECCA SUSAN LIEBERKNECHT PSYCHOLOGICAL ASSIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LIEBERKNECHT
Provider First Name:
REBECCA
Provider Middle Name:
SUSAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PSYCHOLOGICAL ASSIST
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LIEBERKNECHT
Provider Other First Name:
REBECCA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CLINICAL TRAINEE
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1801945811
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3075 ADELINE ST.
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
BERKELEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94703
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-848-1112
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3075 ADELINE ST.
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
BERKELEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-848-1112
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  PSB35555 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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