Healthcare Provider Details

I. General information

NPI: 1770052409
Provider Name (Legal Business Name): KSA YOUTH FOUNDATION INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2018
Last Update Date: 11/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10903 INDIAN HEAD HWY STE 504
FORT WASHINGTON MD
20744-4012
US

IV. Provider business mailing address

10903 INDIAN HEAD HWY STE 504
FORT WASHINGTON MD
20744-4012
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 Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

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