Provider Demographics
NPI:1255368692
Name:LIBOLT, LORI FAYE (OTR,L/CHT)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:FAYE
Last Name:LIBOLT
Suffix:
Gender:F
Credentials:OTR,L/CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 E MABERRY DR
Mailing Address - Street 2:
Mailing Address - City:LYNDEN
Mailing Address - State:WA
Mailing Address - Zip Code:98264-9337
Mailing Address - Country:US
Mailing Address - Phone:360-354-0201
Mailing Address - Fax:
Practice Address - Street 1:1610 GROVER ST STE B2
Practice Address - Street 2:
Practice Address - City:LYNDEN
Practice Address - State:WA
Practice Address - Zip Code:98264-1539
Practice Address - Country:US
Practice Address - Phone:360-354-5245
Practice Address - Fax:360-354-7796
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT00000415225X00000X, 225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Not Answered225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8340549Medicaid