Provider Demographics
NPI:1255717351
Name:WHITE, LIBBY R (PT)
Entity type:Individual
Prefix:
First Name:LIBBY
Middle Name:R
Last Name:WHITE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LIBBY
Other - Middle Name:R
Other - Last Name:BURKLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7238
Practice Address - Street 1:744 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3505
Practice Address - Country:US
Practice Address - Phone:920-445-7222
Practice Address - Fax:920-445-7238
Is Sole Proprietor?:No
Enumeration Date:2015-07-31
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13148-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist