=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073403960
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LARRY WILLIAM LIBBY
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2025
-----------------------------------------------------
Last Update Date | 07/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1942 S 42ND ST STE 122
-----------------------------------------------------
City | OMAHA
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-346-5220
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 324 STEVEN CIR
-----------------------------------------------------
City | COUNCIL BLUFFS
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 51503-0226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-254-6550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 373H00000X
-----------------------------------------------------
Taxonomy Name | Day Training/Habilitation Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------