Basic Information
Provider Information | |||||||||
NPI: | 1720002553 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LIBBY | ||||||||
FirstName: | CHRISTANNA | ||||||||
MiddleName: | HARLOW | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 40 SUMMER ST | ||||||||
Address2: | 2ND FLOOR | ||||||||
City: | BANGOR | ||||||||
State: | ME | ||||||||
PostalCode: | 044017144 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2072991138 | ||||||||
FaxNumber: | 2079903660 | ||||||||
Practice Location | |||||||||
Address1: | 40 SUMMER ST | ||||||||
Address2: | 2ND FLOOR | ||||||||
City: | BANGOR | ||||||||
State: | ME | ||||||||
PostalCode: | 044017144 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2072991138 | ||||||||
FaxNumber: | 2079903660 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/26/2006 | ||||||||
LastUpdateDate: | 05/29/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | CC2973 | ME | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
ID | Type | State | Issuer | Description | 73688869 | 01 | ME | AETNA | OTHER | 100454 | 01 | ME | ANTHEM | OTHER | 431613899 | 05 | ME |   | MEDICAID |