Healthcare Provider Details

I. General information

NPI: 1649433756
Provider Name (Legal Business Name): LIBERTY REHABILITATION SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2008
Last Update Date: 07/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 NORTHMONT RD
WINDSOR MILL MD
21244-2953
US

IV. Provider business mailing address

3333 NORTHMONT RD
WINDSOR MILL MD
21244-2953
US

V. Phone/Fax

Practice location:
  • Phone: 443-621-4884
  • Fax:
Mailing address:
  • Phone: 443-621-4884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number05877
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number05877
License Number StateMD

VIII. Authorized Official

Name: MR. TYRONE JAMES BANKS
Title or Position: OCCUPATIONAL THERAPIST
Credential: MSOTR/L
Phone: 443-621-4884