Healthcare Provider Details

I. General information

NPI: 1710699137
Provider Name (Legal Business Name): AGLOW RECOVERY HEALTHCARE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2022
Last Update Date: 02/14/2023
Certification Date: 02/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1647 BENNING RD NE STE 300A
WASHINGTON DC
20002-4572
US

IV. Provider business mailing address

2490 MARKET ST NE # 630
WASHINGTON DC
20018-3851
US

V. Phone/Fax

Practice location:
  • Phone: 202-621-8713
  • Fax: 202-946-7091
Mailing address:
  • Phone: 202-621-8713
  • Fax: 202-946-7091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KERNIBA Y GHONEIM
Title or Position: CO-OWNER
Credential:
Phone: 202-621-8713