Provider Demographics
NPI:1962698043
Name:EBERLY, LIBERTY ANN (DO)
Entity type:Individual
Prefix:
First Name:LIBERTY
Middle Name:ANN
Last Name:EBERLY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:LIBERTY
Other - Middle Name:ANN
Other - Last Name:TRISSELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:425 HORSE TRAIL WAY
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-6511
Mailing Address - Country:US
Mailing Address - Phone:814-464-4816
Mailing Address - Fax:
Practice Address - Street 1:1330 W 26TH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16508-1402
Practice Address - Country:US
Practice Address - Phone:814-459-9300
Practice Address - Fax:814-454-7782
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-21
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT0113382084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102325895 0001Medicaid
PA102325895 0002Medicaid
PA102325895 0001Medicaid