MEDICARE: PRINCE OF PEACE, INC

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	103TM1800X	Intellectual & Developmental Disabilities Psychologist

General Provider Information

NPI Number	:	1174344881
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRINCE OF PEACE, INC

Provider Business Mailing Address
First Line	:	7512 KELSEYS LN
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21237-3709
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5884 BELAIR RD
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21206-2612
Country	:	US
Telephone Number	:	443-791-0678
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	KELECHI AGUGUO
Credential	:
Telephone Number	:	443-922-8986

Provider Enumeration Date	:	10/24/2024
Last Update Date	:	10/24/2024

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Directions to “PRINCE OF PEACE, INC ” Practice Location

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