Provider Demographics
NPI:1366675761
Name:WETHINGTON, LIBERTY B (CP)
Entity Type:Individual
Prefix:
First Name:LIBERTY
Middle Name:B
Last Name:WETHINGTON
Suffix:
Gender:F
Credentials:CP
Other - Prefix:
Other - First Name:LIBERTY
Other - Middle Name:B
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1401 W MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4250
Mailing Address - Country:US
Mailing Address - Phone:817-923-2101
Mailing Address - Fax:
Practice Address - Street 1:1401 W MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4250
Practice Address - Country:US
Practice Address - Phone:817-923-2101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-01
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1215224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist