Provider Demographics
NPI:1699464180
Name:LIBOCK, ANDRE SERGE
Entity type:Individual
Prefix:
First Name:ANDRE SERGE
Middle Name:
Last Name:LIBOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8309 MINER ST
Mailing Address - Street 2:
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-4404
Mailing Address - Country:US
Mailing Address - Phone:734-322-7744
Mailing Address - Fax:
Practice Address - Street 1:8309 MINER ST
Practice Address - Street 2:
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-4404
Practice Address - Country:US
Practice Address - Phone:734-322-7744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-02
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251S00000XAgenciesCommunity/Behavioral Health