Provider Demographics
NPI:1972001717
Name:LIBERT, SAMANTHA (LADC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:LIBERT
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:MERRY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPCA
Mailing Address - Street 1:1028 BARRET AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40204-1667
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1028 BARRET AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40204-1667
Practice Address - Country:US
Practice Address - Phone:502-451-1221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-26
Last Update Date:2018-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY128572101YP2500X
MN304254101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)