Healthcare Provider Details

I. General information

NPI: 1235474842
Provider Name (Legal Business Name): LIBERTY ADVOCACY GROUP INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2012
Last Update Date: 12/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1043 CHETCO AVE
BROOKINGS OR
97415-7152
US

IV. Provider business mailing address

PO BOX 4404
BROOKINGS OR
97415-0068
US

V. Phone/Fax

Practice location:
  • Phone: 541-469-7611
  • Fax: 866-835-8295
Mailing address:
  • Phone: 541-469-7611
  • Fax: 541-661-2369

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number094003275RN
License Number StateOR

VIII. Authorized Official

Name: MRS. RENEE BALCOM
Title or Position: FOUNDING DIRECTOR
Credential:
Phone: 541-469-7611