Provider Demographics
NPI:1689381667
Name:LIBERATORE, VICKIE LYNN
Entity Type:Individual
Prefix:
First Name:VICKIE
Middle Name:LYNN
Last Name:LIBERATORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 SKOPLEE ST
Mailing Address - Street 2:
Mailing Address - City:GIRARD
Mailing Address - State:OH
Mailing Address - Zip Code:44420-3308
Mailing Address - Country:US
Mailing Address - Phone:330-979-3156
Mailing Address - Fax:
Practice Address - Street 1:819 MCKAY CT STE 102
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-5771
Practice Address - Country:US
Practice Address - Phone:330-259-4849
Practice Address - Fax:330-629-2847
Is Sole Proprietor?:No
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.179718101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)