Provider Demographics
NPI:1144400862
Name:LIBBY, WALTER
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:
Last Name:LIBBY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1695 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-4063
Mailing Address - Country:US
Mailing Address - Phone:541-344-9700
Mailing Address - Fax:
Practice Address - Street 1:1695 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97402-4063
Practice Address - Country:US
Practice Address - Phone:541-344-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-09
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5122172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
5122OtherMASSAGE THERAPIST