Provider Demographics
NPI:1962134247
Name:DEFFENBAUGH, LIBERTY
Entity type:Individual
Prefix:
First Name:LIBERTY
Middle Name:
Last Name:DEFFENBAUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8011 PONDEROSA DR
Mailing Address - Street 2:
Mailing Address - City:SEVERN
Mailing Address - State:MD
Mailing Address - Zip Code:21144-1751
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8011 PONDEROSA DR
Practice Address - Street 2:
Practice Address - City:SEVERN
Practice Address - State:MD
Practice Address - Zip Code:21144-1751
Practice Address - Country:US
Practice Address - Phone:443-569-6905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-27
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP12814101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional