Provider Demographics
NPI:1700973955
Name:LIBRA SUPPORT SERVICES LLC
Entity Type:Organization
Organization Name:LIBRA SUPPORT SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:LUNS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-402-9826
Mailing Address - Street 1:29650 FAITH CT
Mailing Address - Street 2:
Mailing Address - City:CANNON FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:55009-9439
Mailing Address - Country:US
Mailing Address - Phone:651-402-9826
Mailing Address - Fax:
Practice Address - Street 1:29650 FAITH CT
Practice Address - Street 2:
Practice Address - City:CANNON FALLS
Practice Address - State:MN
Practice Address - Zip Code:55009-9439
Practice Address - Country:US
Practice Address - Phone:651-402-9826
Practice Address - Fax:651-402-9826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1041897-1-WS320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN637683500OtherMN HEALTH CARE PROV-MHCP