Provider Demographics
NPI:1124371778
Name:LIBERTY, KENNETH B (PHD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:B
Last Name:LIBERTY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:ME
Mailing Address - Zip Code:04457-4000
Mailing Address - Country:US
Mailing Address - Phone:207-794-6700
Mailing Address - Fax:
Practice Address - Street 1:175 W BROADWAY
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:ME
Practice Address - Zip Code:04457-4000
Practice Address - Country:US
Practice Address - Phone:207-794-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-19
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS1359103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME103T00000XOtherANTHEM BLUE CROSS