Provider Demographics
NPI:1194423830
Name:LIVING FOR LIBERATION
Entity type:Organization
Organization Name:LIVING FOR LIBERATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:BERNICE
Authorized Official - Last Name:WESTPHAL
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW
Authorized Official - Phone:262-226-0391
Mailing Address - Street 1:PO BOX 131
Mailing Address - Street 2:
Mailing Address - City:HUSTISFORD
Mailing Address - State:WI
Mailing Address - Zip Code:53034-0131
Mailing Address - Country:US
Mailing Address - Phone:262-224-7721
Mailing Address - Fax:
Practice Address - Street 1:111 WARREN ST STE 2
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-3084
Practice Address - Country:US
Practice Address - Phone:262-226-0391
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-22
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty