Provider Demographics
NPI:1659026433
Name:LIBERATEABQ, LLC
Entity Type:Organization
Organization Name:LIBERATEABQ, LLC
Other - Org Name:LIBERATEABQ
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:505-596-0614
Mailing Address - Street 1:609 GOLD AVE SW STE 1F
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-3119
Mailing Address - Country:US
Mailing Address - Phone:505-758-7200
Mailing Address - Fax:
Practice Address - Street 1:609 GOLD AVE SW STE 1F
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-3119
Practice Address - Country:US
Practice Address - Phone:505-758-7200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-19
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM04123751Medicaid