Provider Demographics
NPI:1023584398
Name:LALIBERTE, BENJAMIN (PHD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:
Last Name:LALIBERTE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1194
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1194
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2870 NE WEST DEVILS LAKE RD
Practice Address - Street 2:
Practice Address - City:LINCOLN CITY
Practice Address - State:OR
Practice Address - Zip Code:97367-5127
Practice Address - Country:US
Practice Address - Phone:541-994-9191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-15
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301017255103TC0700X
OR3262103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6301017255OtherLICENSED PSYCHOLOGIST