Healthcare Provider Details

I. General information

NPI: 1578794525
Provider Name (Legal Business Name): MRS. MARY JANE LYBYER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2009
Last Update Date: 08/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

423 W. PINE
HOUSTON MO
65483
US

IV. Provider business mailing address

12743 HIGHWAY 38
HUGGINS MO
65484-9108
US

V. Phone/Fax

Practice location:
  • Phone: 417-967-3196
  • Fax: 417-967-4479
Mailing address:
  • Phone: 417-967-3196
  • Fax: 417-967-4479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number0443653
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: