Healthcare Provider Details

I. General information

NPI: 1760054522
Provider Name (Legal Business Name): LIBERATED COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2021
Last Update Date: 10/05/2023
Certification Date: 10/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 ALISO DR SE
ALBUQUERQUE NM
87108-2693
US

IV. Provider business mailing address

PO BOX 3258
OREGON CITY OR
97045-0821
US

V. Phone/Fax

Practice location:
  • Phone: 505-504-5449
  • Fax:
Mailing address:
  • Phone: 505-504-5449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN RATCLIFF
Title or Position: OWNER
Credential:
Phone: 505-504-5449