Provider Demographics
NPI:1306962428
Name:ANG, LIBERTY JAVENIA (PT)
Entity type:Individual
Prefix:MRS
First Name:LIBERTY
Middle Name:JAVENIA
Last Name:ANG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 MERRITT
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-4808
Mailing Address - Country:US
Mailing Address - Phone:505-409-8290
Mailing Address - Fax:
Practice Address - Street 1:1000 E AZTEC AVE
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5509
Practice Address - Country:US
Practice Address - Phone:505-721-1839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3162225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist