Healthcare Provider Details

I. General information

NPI: 1831423078
Provider Name (Legal Business Name): TED LIBERTY LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2009
Last Update Date: 11/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1940 HARRISON AVE
PANAMA CITY FL
32405-4542
US

IV. Provider business mailing address

1940 HARRISON AVE
PANAMA CITY FL
32405-4542
US

V. Phone/Fax

Practice location:
  • Phone: 850-763-0017
  • Fax: 850-532-6454
Mailing address:
  • Phone: 850-763-0017
  • Fax: 850-532-6454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH16073
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC005678
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: