1164610598 NPI number — GARY P. LIABOE, PHD, LP, LLC

Table of content: (NPI 1164610598)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164610598 NPI number — GARY P. LIABOE, PHD, LP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GARY P. LIABOE, PHD, LP, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164610598
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/08/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3820 CLEVELAND AVE N
Provider Second Line Business Mailing Address:
ST 400
Provider Business Mailing Address City Name:
ARDEN HILLS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55112-3285
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-389-4400
Provider Business Mailing Address Fax Number:
651-389-4410

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3820 CLEVELAND AVE N
Provider Second Line Business Practice Location Address:
ST 400
Provider Business Practice Location Address City Name:
ARDEN HILLS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55112-3285
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-389-4400
Provider Business Practice Location Address Fax Number:
651-389-4410
Provider Enumeration Date:
10/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LIABOE
Authorized Official First Name:
GARY
Authorized Official Middle Name:
P
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
651-389-4400

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  LP0737 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 324L6CO . This is a "BLUECROSS/BLUESHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 80174310 . This is a "WAUSAU" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 97095547005 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 191366 . This is a "VALUE OPTIONS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 6142913 . This is a "UNITED BEHARIORAL HEALTH" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 8017430 . This is a "PATIENT CHOICE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 232253 . This is a "PACIFIC LIFE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 0005947146 . This is a "AETNA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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