Provider Demographics
NPI:1659736999
Name:LIBBY, MICHAEL ERIC
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ERIC
Last Name:LIBBY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 CHESTNUT ST APT 314
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-8069
Mailing Address - Country:US
Mailing Address - Phone:207-740-5752
Mailing Address - Fax:
Practice Address - Street 1:4 PARK ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-7172
Practice Address - Country:US
Practice Address - Phone:207-784-0922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-30
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECAC5583101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)