Healthcare Provider Details

I. General information

NPI: 1679165773
Provider Name (Legal Business Name): LIBERTY LAKE COUPLE AND FAMILY THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2021
Last Update Date: 10/20/2025
Certification Date: 10/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1334 N WHITMAN LN STE 140
LIBERTY LAKE WA
99019-6034
US

IV. Provider business mailing address

18621 E ALKI AVE
SPOKANE VALLEY WA
99016-9505
US

V. Phone/Fax

Practice location:
  • Phone: 509-443-5015
  • Fax: 509-443-5373
Mailing address:
  • Phone: 509-443-5015
  • Fax: 509-443-5373

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 Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: MRS. CARMEN MH GREEN
Title or Position: THERAPIST
Credential: LMFT, LMHC
Phone: 509-443-5015