Basic Information
Provider Information | |||||||||
NPI: | 1710455936 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LIEB | ||||||||
FirstName: | JENA | ||||||||
MiddleName: | LIANE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PSYD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 700 8TH AVE W STE 101 | ||||||||
Address2: |   | ||||||||
City: | PALMETTO | ||||||||
State: | FL | ||||||||
PostalCode: | 342214737 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9417764000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 725 N 12TH AVE BLDG B | ||||||||
Address2: |   | ||||||||
City: | ARCADIA | ||||||||
State: | FL | ||||||||
PostalCode: | 342668752 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8634941242 | ||||||||
FaxNumber: | 8634910466 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/06/2018 | ||||||||
LastUpdateDate: | 03/11/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PY10313 | FL | Y |   | Behavioral Health & Social Service Providers | Psychologist |   |
No ID Information.