Provider Demographics
NPI:1073331898
Name:ANDERSON, LIBBY (EDS)
Entity type:Individual
Prefix:
First Name:LIBBY
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7388 N 750 W
Mailing Address - Street 2:
Mailing Address - City:FRANKTON
Mailing Address - State:IN
Mailing Address - Zip Code:46044-9467
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1303 STATE ROAD 128 E
Practice Address - Street 2:
Practice Address - City:FRANKTON
Practice Address - State:IN
Practice Address - Zip Code:46044-9206
Practice Address - Country:US
Practice Address - Phone:765-754-7545
Practice Address - Fax:765-754-8598
Is Sole Proprietor?:No
Enumeration Date:2024-10-01
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10101196103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool