MEDICARE: DR. ROGER WILLIAM LIBBY LICENSE MENTAL HEALT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	RC00028232	WA
2	101YM0800X	Mental Health Counselor	LH60106663	WA

General Provider Information

NPI Number	:	1558400895
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROGER WILLIAM LIBBY LICENSE MENTAL HEALT

Provider Business Mailing Address
First Line	:	PO BOX 578
Second Line	:
City	:	KINGSTON
State	:	WA
Zip	:	98346-0578
Country	:	US
Telephone Number	:	206-550-6424
Fax Number	:	360-881-0222

Provider Business Practice Location Address
First Line	:	17791 FJORD DR NE
Second Line	:	R
City	:	POULSBO
State	:	WA
Zip	:	98370-8481
Country	:	US
Telephone Number	:	360-394-4568
Fax Number	:	360-881-0222

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/05/2007
Last Update Date	:	07/27/2010

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