Provider Demographics
NPI:1942027909
Name:LIBERTY, EMILIE
Entity type:Individual
Prefix:
First Name:EMILIE
Middle Name:
Last Name:LIBERTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2347 BENJAMIN ST NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55418-4001
Mailing Address - Country:US
Mailing Address - Phone:320-281-9595
Mailing Address - Fax:
Practice Address - Street 1:2347 BENJAMIN ST NE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55418-4001
Practice Address - Country:US
Practice Address - Phone:320-281-9595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center