=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225192594
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LILA L ROBERTS-BIRD DBA LIBERTY COUNSELING MSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2006
-----------------------------------------------------
Last Update Date | 08/28/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 315 E JEFFERSON ST
-----------------------------------------------------
City | WAUPUN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53963-2032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-210-7181
-----------------------------------------------------
Fax | 920-324-5700
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 141 W HURON ST
-----------------------------------------------------
City | BERLIN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54923-1545
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-210-7181
-----------------------------------------------------
Fax | 920-361-2334
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 1827-123
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 448-124
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------