Provider Demographics
NPI:1316121510
Name:LIEBERUM, SANDY K
Entity type:Individual
Prefix:MS
First Name:SANDY
Middle Name:K
Last Name:LIEBERUM
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 1:15870 ROUTE 322
Mailing Address - Street 2:STE. 2
Mailing Address - City:CLARION
Mailing Address - State:PA
Mailing Address - Zip Code:16214
Mailing Address - Country:US
Mailing Address - Phone:814-764-6066
Mailing Address - Fax:814-764-5669
Practice Address - Street 1:15870 ROUTE 322
Practice Address - Street 2:STE. 2
Practice Address - City:CLARION
Practice Address - State:PA
Practice Address - Zip Code:16214-6376
Practice Address - Country:US
Practice Address - Phone:814-764-6066
Practice Address - Fax:814-764-5669
Is Sole Proprietor?:No
Enumeration Date:2007-12-24
Last Update Date:2007-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1012910120001Medicaid