Provider Demographics
NPI:1619531217
Name:LIBBEY, ANTIQUA LISHA (MA)
Entity Type:Individual
Prefix:
First Name:ANTIQUA
Middle Name:LISHA
Last Name:LIBBEY
Suffix:
Gender:F
Credentials:MA
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 879461
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99687-9461
Mailing Address - Country:US
Mailing Address - Phone:907-354-4345
Mailing Address - Fax:
Practice Address - Street 1:4821 S OUTRIGGER DR.
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99687
Practice Address - Country:US
Practice Address - Phone:907-354-4345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-29
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK$$$$$$$$$Medicaid