Provider Demographics
NPI:1235474842
Name:LIBERTY ADVOCACY GROUP INC.
Entity type:Organization
Organization Name:LIBERTY ADVOCACY GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDING DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:
Authorized Official - Last Name:BALCOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-469-7611
Mailing Address - Street 1:PO BOX 4404
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97415-0068
Mailing Address - Country:US
Mailing Address - Phone:541-469-7611
Mailing Address - Fax:541-661-2369
Practice Address - Street 1:1043 CHETCO AVE
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415-7152
Practice Address - Country:US
Practice Address - Phone:541-469-7611
Practice Address - Fax:866-835-8295
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-07
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
OR094003275RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty