Provider Demographics
NPI:1861000523
Name:LIBAK, ALYSSA JOY
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:JOY
Last Name:LIBAK
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 1:601 PALO ALTO DR
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-6626
Mailing Address - Country:US
Mailing Address - Phone:360-624-0870
Mailing Address - Fax:
Practice Address - Street 1:9115 SW OLESON RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-6875
Practice Address - Country:US
Practice Address - Phone:877-910-6538
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-20
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician