=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003264342
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEW BEGINNINGS WELLNESS CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2016
-----------------------------------------------------
Last Update Date | 05/26/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10410 KENSINGTON PKWY SUITE 104
-----------------------------------------------------
City | KENSINGTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20895-2943
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-903-4269
-----------------------------------------------------
Fax | 202-509-9050
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10410 KENSINGTON PKWY SUITE 104
-----------------------------------------------------
City | KENSINGTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20895-2943
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-903-4269
-----------------------------------------------------
Fax | 202-509-9050
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO, CLINICAL DIRECTOR
-----------------------------------------------------
Name | DR. SONYA CLYBURN
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 202-903-4269
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 05441
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------