Provider Demographics
NPI:1104312875
Name:LIBERTY, AMANDA LEIGH (PMHNP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEIGH
Last Name:LIBERTY
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:LEIGH
Other - Last Name:ORTIZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PMHNP
Mailing Address - Street 1:1069 CENTRAL ST
Mailing Address - Street 2:
Mailing Address - City:LEOMINSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01453-4805
Mailing Address - Country:US
Mailing Address - Phone:978-728-4957
Mailing Address - Fax:978-798-1366
Practice Address - Street 1:1069 CENTRAL ST
Practice Address - Street 2:
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453-4805
Practice Address - Country:US
Practice Address - Phone:978-728-4957
Practice Address - Fax:978-798-1366
Is Sole Proprietor?:No
Enumeration Date:2018-07-06
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2313229363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health