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General NPI Number Information
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NPI Number | 1629889860
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Entity Type | Organization
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Legal Business Name | LIBERTY WELLNESS INDIVIDUAL AND FAMILY THERAPY
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Dates
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Enumeration Date | 01/16/2025
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Last Update Date | 01/16/2025
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Provider Practice Location Address
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Address Line | 400 S 2ND AVE STE 105
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City | BARSTOW
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State | CA
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Zip | 92311-2805
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Country | US
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Telephone | 760-282-4099
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Fax | 855-211-3331
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Provider Business Mailing Address
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Address Line | PO BOX 1181
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City | YERMO
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State | CA
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Zip | 92398-1181
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Country | US
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Telephone | 760-282-4099
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Fax | 855-211-3331
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Authorized Official
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Title or Position | CEO
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Name | MS. LIBERTY WYMAN
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Credential | LMFT
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Telephone | 760-282-4099
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number |
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License Number State |
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