Provider Demographics
NPI:1154762367
Name:VIERRA, LIBERTY
Entity type:Individual
Prefix:
First Name:LIBERTY
Middle Name:
Last Name:VIERRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7310 N BADER RD
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-8013
Mailing Address - Country:US
Mailing Address - Phone:928-814-8322
Mailing Address - Fax:
Practice Address - Street 1:7310 N BADER RD
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-8013
Practice Address - Country:US
Practice Address - Phone:928-814-8322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-16
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4473415385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child