Provider Demographics
NPI:1619904588
Name:LIBBY, MARK SHERWOOD (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:SHERWOOD
Last Name:LIBBY
Suffix:
Gender:M
Credentials:PT
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 28
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:VT
Mailing Address - Zip Code:05091-0028
Mailing Address - Country:US
Mailing Address - Phone:802-457-4213
Mailing Address - Fax:802-457-9870
Practice Address - Street 1:10606 RT 106 SOUTH
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:VT
Practice Address - Zip Code:05091
Practice Address - Country:US
Practice Address - Phone:802-457-4213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040 0003101225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT38849OtherBLUE CROSS/BLUE SHIELD
VT439910OtherMVP
VTOVN1901Medicaid
VT439910OtherMVP