Basic Information
| Provider Information | |||||||||
| NPI: | 1639208309 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | LIBBY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSY.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BETHEL | ||||||||
| OtherFirstName: | LIBBY | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 3276 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477313276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124730181 | ||||||||
| FaxNumber: | 8124735822 | ||||||||
| Practice Location | |||||||||
| Address1: | 7409 EAGLE CREST BLVD STE G | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477159136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128424020 | ||||||||
| FaxNumber: | 8128424019 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 05/22/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 1068 | KY | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103T00000X | 20041288A | IN | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 7100153380 | 05 | KY | MEDICAID | 000000709939 | 01 | KY | ANTHEM BC/BS | OTHER | 20041288A | 01 | IN | STATE LICENSE | OTHER | 300017911 | 05 | IN | MEDICAID |