Provider Demographics
NPI:1942539465
Name:LIBBY, PATRICIA
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:LIBBY
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 1:123 DEMERITT RD
Mailing Address - Street 2:
Mailing Address - City:WEST NEWFIELD
Mailing Address - State:ME
Mailing Address - Zip Code:04095-3427
Mailing Address - Country:US
Mailing Address - Phone:207-793-4567
Mailing Address - Fax:
Practice Address - Street 1:123 DEMERITT RD
Practice Address - Street 2:
Practice Address - City:WEST NEWFIELD
Practice Address - State:ME
Practice Address - Zip Code:04095-3427
Practice Address - Country:US
Practice Address - Phone:207-793-4567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-11
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME202140000Medicaid