Basic Information
| Provider Information | |||||||||
| NPI: | 1215224233 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIBERTY | ||||||||
| FirstName: | WILLIE-JOE | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 569 | ||||||||
| Address2: | |||||||||
| City: | RANGELEY | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049700569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078642699 | ||||||||
| FaxNumber: | 2078642969 | ||||||||
| Practice Location | |||||||||
| Address1: | 24 GARDINER ST | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077375349 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2011 | ||||||||
| LastUpdateDate: | 12/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | MC13100 | ME | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | LC14369 | ME | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.