MEDICARE: LIBBY PSYCHOLOGICAL WELLNESS CENTER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	04557	MD

General Provider Information

NPI Number	:	1063914406
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIBBY PSYCHOLOGICAL WELLNESS CENTER, LLC

Provider Business Mailing Address
First Line	:	1315 BLACKWALNUT CT
Second Line	:
City	:	ANNAPOLIS
State	:	MD
Zip	:	21403-4660
Country	:	US
Telephone Number	:	443-223-1542
Fax Number	:

Provider Business Practice Location Address
First Line	:	1298 BAY DALE DR STE 216
Second Line	:
City	:	ARNOLD
State	:	MD
Zip	:	21012-2826
Country	:	US
Telephone Number	:	443-223-1542
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KIMBERLY MEYERS-LIBBY
Credential	:	PSY.D
Telephone Number	:	443-223-1542

Provider Enumeration Date	:	03/01/2018
Last Update Date	:	03/01/2018

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