Healthcare Provider Details

I. General information

NPI: 1952008880
Provider Name (Legal Business Name): ACTIVISION FIDELITY PSYCHIATRIC MENTAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2023
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6475 NEW HAMPSHIRE AVE
HYATTSVILLE MD
20783-3269
US

IV. Provider business mailing address

2409 BAIKAL LOOP
UPPER MARLBORO MD
20774-7051
US

V. Phone/Fax

Practice location:
  • Phone: 301-907-1199
  • Fax: 240-342-3440
Mailing address:
  • Phone: 301-907-1199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KENNY AMANZE
Title or Position: PRESIDENT
Credential: CRNP-PMH
Phone: 301-907-1199