Provider Demographics
NPI:1073173894
Name:LIBERTINI, KIM ELLEN
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:ELLEN
Last Name:LIBERTINI
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 1:245 HILLTOP CT
Mailing Address - Street 2:
Mailing Address - City:NEW FREEDOM
Mailing Address - State:PA
Mailing Address - Zip Code:17349-9078
Mailing Address - Country:US
Mailing Address - Phone:717-235-6738
Mailing Address - Fax:
Practice Address - Street 1:245 HILLTOP CT
Practice Address - Street 2:
Practice Address - City:NEW FREEDOM
Practice Address - State:PA
Practice Address - Zip Code:17349-9078
Practice Address - Country:US
Practice Address - Phone:717-235-6738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-14
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01264235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
00791426OtherASHA
MD01246OtherSTATE LICENSE