Healthcare Provider Details

I. General information

NPI: 1972298883
Provider Name (Legal Business Name): MR. MICHAEL G LLIBBY JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2023
Last Update Date: 04/06/2023
Certification Date: 04/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 7TH AVE N
SAINT CLOUD MN
56303-4753
US

IV. Provider business mailing address

14 7TH AVE N
SAINT CLOUD MN
56303-4753
US

V. Phone/Fax

Practice location:
  • Phone: 320-492-1787
  • Fax:
Mailing address:
  • Phone: 320-492-1787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: