Healthcare Provider Details

I. General information

NPI: 1285255307
Provider Name (Legal Business Name): KENAH ONE HEALTH CARE SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2020
Last Update Date: 11/29/2021
Certification Date: 11/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 CRAIN HWY N
GLEN BURNIE MD
21061-3090
US

IV. Provider business mailing address

7735 HOLLINS CHAPEL CT
GLEN BURNIE MD
21060-8396
US

V. Phone/Fax

Practice location:
  • Phone: 443-465-9958
  • Fax:
Mailing address:
  • Phone: 443-465-9958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number StateNULL

VIII. Authorized Official

Name: KETTY NGONA
Title or Position: PROGRAM DIRECTOR
Credential: CRNP, PMH-BC
Phone: 443-465-9958