Provider Demographics
NPI:1578182986
Name:LIBERTAS LEADERSHIP LLC
Entity Type:Organization
Organization Name:LIBERTAS LEADERSHIP LLC
Other - Org Name:LIBERTAS INTEGRATIVE HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:540-613-1825
Mailing Address - Street 1:1043 OAKLAWN DR STE A
Mailing Address - Street 2:
Mailing Address - City:CULPEPER
Mailing Address - State:VA
Mailing Address - Zip Code:22701-3339
Mailing Address - Country:US
Mailing Address - Phone:540-613-1825
Mailing Address - Fax:540-870-6133
Practice Address - Street 1:1043 OAKLAWN DR STE A
Practice Address - Street 2:
Practice Address - City:CULPEPER
Practice Address - State:VA
Practice Address - Zip Code:22701-3339
Practice Address - Country:US
Practice Address - Phone:540-613-1825
Practice Address - Fax:540-870-6133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-15
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1497732549Medicaid