Healthcare Provider Details

I. General information

NPI: 1629889860
Provider Name (Legal Business Name): LIBERTY WELLNESS INDIVIDUAL AND FAMILY THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2025
Last Update Date: 01/16/2025
Certification Date: 01/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S 2ND AVE STE 105
BARSTOW CA
92311-2805
US

IV. Provider business mailing address

PO BOX 1181
YERMO CA
92398-1181
US

V. Phone/Fax

Practice location:
  • Phone: 760-282-4099
  • Fax: 855-211-3331
Mailing address:
  • Phone: 760-282-4099
  • Fax: 855-211-3331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: MS. LIBERTY WYMAN
Title or Position: CEO
Credential: LMFT
Phone: 760-282-4099