Provider Demographics
NPI:1649497793
Name:LIBERTAE, INC.
Entity type:Organization
Organization Name:LIBERTAE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:BASTEK
Authorized Official - Last Name:KARASOW
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:215-639-8681
Mailing Address - Street 1:5245 BENSALEM BLVD
Mailing Address - Street 2:
Mailing Address - City:BENSALEM
Mailing Address - State:PA
Mailing Address - Zip Code:19020-4076
Mailing Address - Country:US
Mailing Address - Phone:215-639-8681
Mailing Address - Fax:215-639-4277
Practice Address - Street 1:5245 BENSALEM BLVD
Practice Address - Street 2:
Practice Address - City:BENSALEM
Practice Address - State:PA
Practice Address - Zip Code:19020-4076
Practice Address - Country:US
Practice Address - Phone:215-639-8681
Practice Address - Fax:215-639-4277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA097074251S00000X
PA093149251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001627736Medicaid
PA0016277360001Medicaid