Healthcare Provider Details

I. General information

NPI: 1467380006
Provider Name (Legal Business Name): MR. MICHAEL UGOCHUKWU UDEAGWU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5013 CANVASBACK CT
FREDERICK MD
21703-9510
US

IV. Provider business mailing address

5013 CANVASBACK CT
FREDERICK MD
21703-9510
US

V. Phone/Fax

Practice location:
  • Phone: 443-657-3415
  • Fax:
Mailing address:
  • Phone: 443-657-3415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: