Provider Demographics
NPI:1144356130
Name:LEE, LIBBIE ANN (DPT)
Entity type:Individual
Prefix:DR
First Name:LIBBIE
Middle Name:ANN
Last Name:LEE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:DR
Other - First Name:LIBBIE
Other - Middle Name:ANN
Other - Last Name:MANGUM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPT
Mailing Address - Street 1:405 W MAIN ST.
Mailing Address - Street 2:SUITE D
Mailing Address - City:PAYSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85541-3549
Mailing Address - Country:US
Mailing Address - Phone:928-474-0429
Mailing Address - Fax:928-474-0199
Practice Address - Street 1:405 W. MAIN ST.
Practice Address - Street 2:SUITE D
Practice Address - City:PAYSON
Practice Address - State:AZ
Practice Address - Zip Code:85541
Practice Address - Country:US
Practice Address - Phone:928-474-0429
Practice Address - Fax:928-474-0199
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9274225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ852420Medicaid
AZZ162254Medicare PIN