Provider Demographics
NPI:1215016654
Name:LIBERATOR, MATTHEW A (LPC)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:A
Last Name:LIBERATOR
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:9504 E 63RD ST
Mailing Address - Street 2:SUITE 213
Mailing Address - City:RAYTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:64133-4948
Mailing Address - Country:US
Mailing Address - Phone:913-894-3550
Mailing Address - Fax:816-356-0894
Practice Address - Street 1:9504 E 63RD ST
Practice Address - Street 2:SUITE 213
Practice Address - City:RAYTOWN
Practice Address - State:MO
Practice Address - Zip Code:64133-4948
Practice Address - Country:US
Practice Address - Phone:913-894-3550
Practice Address - Fax:816-356-0894
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO001215101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO20641015OtherBLUE CROSS BLUESHIELD