MEDICARE: POSITIVE BEHAVIORAL HEALTH SERVICES

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)

General Provider Information

NPI Number	:	1780526210
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POSITIVE BEHAVIORAL HEALTH SERVICES

Provider Business Mailing Address
First Line	:	11805 PIKA DR
Second Line	:
City	:	WALDORF
State	:	MD
Zip	:	20602-3732
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11805 PIKA DR
Second Line	:
City	:	WALDORF
State	:	MD
Zip	:	20602-3732
Country	:	US
Telephone Number	:	734-322-7744
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	ANDRE SERGE LIBOCK
Credential	:
Telephone Number	:	734-322-7744

Provider Enumeration Date	:	04/06/2026
Last Update Date	:	04/06/2026

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