Provider Demographics
NPI:1730979261
Name:LIBENGOOD, MACKENZIE
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:LIBENGOOD
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 1:110 MALL CIR
Mailing Address - Street 2:SUITE 2001
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603
Mailing Address - Country:US
Mailing Address - Phone:301-705-8450
Mailing Address - Fax:
Practice Address - Street 1:110 MALL CIRCLE
Practice Address - Street 2:SUITE 2001
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602
Practice Address - Country:US
Practice Address - Phone:301-705-8444
Practice Address - Fax:301-705-8448
Is Sole Proprietor?:No
Enumeration Date:2025-05-08
Last Update Date:2025-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MDTA3086152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program