Provider Demographics
NPI:1912685975
Name:LIBBY, DEREK (CADC, MHRTC)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:LIBBY
Suffix:
Gender:M
Credentials:CADC, MHRTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 PARTRIDGE PL
Mailing Address - Street 2:
Mailing Address - City:CHELSEA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-1296
Mailing Address - Country:US
Mailing Address - Phone:603-204-4919
Mailing Address - Fax:
Practice Address - Street 1:21 PARTRIDGE PL
Practice Address - Street 2:
Practice Address - City:CHELSEA
Practice Address - State:ME
Practice Address - Zip Code:04330-1296
Practice Address - Country:US
Practice Address - Phone:603-204-4919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECAC8536101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)