Provider Demographics
NPI:1619686391
Name:LIBBERT, MALLORY BREANNE (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:BREANNE
Last Name:LIBBERT
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2131 W 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47546-9720
Mailing Address - Country:US
Mailing Address - Phone:812-827-1062
Mailing Address - Fax:
Practice Address - Street 1:3150 SAINT CHARLES ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:IN
Practice Address - Zip Code:47546-1858
Practice Address - Country:US
Practice Address - Phone:812-634-6570
Practice Address - Fax:812-634-7919
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-21
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22006418A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist