Basic Information
Provider Information | |||||||||
NPI: | 1609236330 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LIBERTY RESOURCES FAMILY SERVICES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1045 JAMES ST | ||||||||
Address2: |   | ||||||||
City: | SYRACUSE | ||||||||
State: | NY | ||||||||
PostalCode: | 132032730 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3154251004 | ||||||||
FaxNumber: | 3154797884 | ||||||||
Practice Location | |||||||||
Address1: | 5151 FLYNN PKWY STE 100 | ||||||||
Address2: |   | ||||||||
City: | CORPUS CHRISTI | ||||||||
State: | TX | ||||||||
PostalCode: | 784114318 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3614469752 | ||||||||
FaxNumber: | 3614523180 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/23/2016 | ||||||||
LastUpdateDate: | 01/13/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | COYLE | ||||||||
AuthorizedOfficialFirstName: | CARL | ||||||||
AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 3154251004 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/13/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   |   | N |   | Agencies | Community/Behavioral Health |   | 101YP2500X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.