MEDICARE: LIBERTY TREATMENT PLLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	104100000X	Social Worker
3	101YM0800X	Mental Health Counselor
4	101YP2500X	Professional Counselor
5	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1942019583
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIBERTY TREATMENT PLLC

Provider Business Mailing Address
First Line	:	1144 WESTERN BLVD # 1122
Second Line	:
City	:	JACKSONVILLE
State	:	NC
Zip	:	28546-6651
Country	:	US
Telephone Number	:	910-996-3115
Fax Number	:	910-613-0016

Provider Business Practice Location Address
First Line	:	95 H2O PL
Second Line	:	STE 11
City	:	HAMPSTEAD
State	:	NC
Zip	:	28443
Country	:	US
Telephone Number	:	910-996-3115
Fax Number	:	910-613-0016

Authorized Official
Title or Position	:	OWNER
Name	:	GINA ROSE
Credential	:	LCSW
Telephone Number	:	959-226-8411

Provider Enumeration Date	:	01/07/2025
Last Update Date	:	04/16/2026

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