Provider Demographics
NPI:1093859589
Name:LIBERATO, BEVERLY
Entity Type:Individual
Prefix:MRS
First Name:BEVERLY
Middle Name:
Last Name:LIBERATO
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 1:136 KINOOLE ST
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-2816
Mailing Address - Country:US
Mailing Address - Phone:808-974-4300
Mailing Address - Fax:808-974-4310
Practice Address - Street 1:37 KEKAULIKE ST
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-2462
Practice Address - Country:US
Practice Address - Phone:808-974-4300
Practice Address - Fax:808-974-4310
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI104100000X
HILCSW - 32821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI539372-15Medicaid