Provider Demographics
NPI:1558400895
Name:LIBBY, ROGER WILLIAM (LICENSE MENTAL HEALT)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:WILLIAM
Last Name:LIBBY
Suffix:
Gender:M
Credentials:LICENSE MENTAL HEALT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 578
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:WA
Mailing Address - Zip Code:98346-0578
Mailing Address - Country:US
Mailing Address - Phone:206-550-6424
Mailing Address - Fax:360-881-0222
Practice Address - Street 1:17791 FJORD DR NE
Practice Address - Street 2:R
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-8481
Practice Address - Country:US
Practice Address - Phone:360-394-4568
Practice Address - Fax:360-881-0222
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00028232101YM0800X
WALH60106663101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health