Provider Demographics
NPI:1114559671
Name:VEGAS, LIBERTI E
Entity Type:Individual
Prefix:
First Name:LIBERTI
Middle Name:E
Last Name:VEGAS
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 1:1129 MIAMISBURG CENTERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:WEST CARROLLTON
Mailing Address - State:OH
Mailing Address - Zip Code:45449-4004
Mailing Address - Country:US
Mailing Address - Phone:937-776-9497
Mailing Address - Fax:
Practice Address - Street 1:1129 MIAMISBURG CENTERVILLE RD STE 202
Practice Address - Street 2:
Practice Address - City:WEST CARROLLTON
Practice Address - State:OH
Practice Address - Zip Code:45449-4008
Practice Address - Country:US
Practice Address - Phone:216-659-6986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-12
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.2107143104100000X
OHS1901198-TRNE390200000X
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program