Provider Demographics
NPI:1295408623
Name:LIBSTAG, ALEXANDRA
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:LIBSTAG
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 1:39 SURREY ST # 2
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-2722
Mailing Address - Country:US
Mailing Address - Phone:802-318-3037
Mailing Address - Fax:
Practice Address - Street 1:1153 CENTRE ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02130-3446
Practice Address - Country:US
Practice Address - Phone:617-983-7216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-30
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical