Provider Demographics
NPI:1104255058
Name:LIBBEY, MARIE D
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:D
Last Name:LIBBEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:DOROTHEA MCGRATH
Other - Last Name:LIBBEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PMHNP-BC
Mailing Address - Street 1:267 SPENCER ST
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-2574
Mailing Address - Country:US
Mailing Address - Phone:248-346-7316
Mailing Address - Fax:
Practice Address - Street 1:21751 W 11 MILE RD
Practice Address - Street 2:SUITE #105
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-3712
Practice Address - Country:US
Practice Address - Phone:248-327-7175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-01
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704251238363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health