Healthcare Provider Details

I. General information

NPI: 1720551450
Provider Name (Legal Business Name): KSA YOUTH FOUNDATION INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2019
Last Update Date: 01/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2829 CHESAPEAKE BEACH RD W
DUNKIRK MD
20754-9526
US

IV. Provider business mailing address

PO BOX 703
ACCOKEEK MD
20607-0703
US

V. Phone/Fax

Practice location:
  • Phone: 240-766-4194
  • Fax: 301-485-0363
Mailing address:
  • Phone: 240-766-4194
  • Fax: 301-485-0363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: KATRINA WILKINS-JACKSON
Title or Position: CEO
Credential:
Phone: 240-766-4194