MEDICARE: VICKIE LYNN LIBERATORE

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	CDCA.179718	OH

General Provider Information

NPI Number	:	1689381667
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VICKIE LYNN LIBERATORE

Provider Business Mailing Address
First Line	:	39 SKOPLEE ST
Second Line	:
City	:	GIRARD
State	:	OH
Zip	:	44420-3308
Country	:	US
Telephone Number	:	330-979-3156
Fax Number	:

Provider Business Practice Location Address
First Line	:	819 MCKAY CT STE 102
Second Line	:
City	:	BOARDMAN
State	:	OH
Zip	:	44512-5771
Country	:	US
Telephone Number	:	330-259-4849
Fax Number	:	330-629-2847

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

Provider Enumeration Date	:	10/31/2022
Last Update Date	:	10/31/2022

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Directions to “ VICKIE LYNN LIBERATORE ” Practice Location

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