Provider Demographics
NPI:1629889860
Name:LIBERTY WELLNESS INDIVIDUAL AND FAMILY THERAPY
Entity type:Organization
Organization Name:LIBERTY WELLNESS INDIVIDUAL AND FAMILY THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:LIBERTY
Authorized Official - Middle Name:
Authorized Official - Last Name:WYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:760-282-4099
Mailing Address - Street 1:PO BOX 1181
Mailing Address - Street 2:
Mailing Address - City:YERMO
Mailing Address - State:CA
Mailing Address - Zip Code:92398-1181
Mailing Address - Country:US
Mailing Address - Phone:760-282-4099
Mailing Address - Fax:855-211-3331
Practice Address - Street 1:400 S 2ND AVE STE 105
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311-2805
Practice Address - Country:US
Practice Address - Phone:760-282-4099
Practice Address - Fax:855-211-3331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-16
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty