MEDICARE: AWESOME EXPERIENCE PSYCHIATRIC SERVICES LLC

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	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1457949018
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AWESOME EXPERIENCE PSYCHIATRIC SERVICES LLC

Provider Business Mailing Address
First Line	:	5557 BALTIMORE AVE STE 500
Second Line	:
City	:	HYATTSVILLE
State	:	MD
Zip	:	20781-1922
Country	:	US
Telephone Number	:	202-921-4211
Fax Number	:

Provider Business Practice Location Address
First Line	:	5557 BALTIMORE AVE STE 500
Second Line	:
City	:	HYATTSVILLE
State	:	MD
Zip	:	20781-1922
Country	:	US
Telephone Number	:	202-921-4211
Fax Number	:

Authorized Official
Title or Position	:	PROVIDER
Name	:	SIYAMI TAKHA
Credential	:	DNP
Telephone Number	:	202-705-4133

Provider Enumeration Date	:	01/08/2021
Last Update Date	:	01/08/2021

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