Healthcare Provider Details

I. General information

NPI: 1215327259
Provider Name (Legal Business Name): KENNEDY KRIEGER ASSOCIATES, INC - MENTAL HEALTH GROUP PROVIDER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2015
Last Update Date: 09/16/2020
Certification Date: 09/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 N. BROADWAY
BALTIMORE MD
21205
US

IV. Provider business mailing address

P.O. BOX 744865
ATLANTA GA
30374
US

V. Phone/Fax

Practice location:
  • Phone: 443-923-9200
  • Fax: 443-923-9405
Mailing address:
  • Phone: 443-923-1872
  • Fax: 443-923-1875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. MIKE J NEUMAN
Title or Position: VICE PRESIDENT FINANCE
Credential:
Phone: 443-923-1810