Healthcare Provider Details

I. General information

NPI: 1316522006
Provider Name (Legal Business Name): FAIRLAND BEHAVIORAL HEALTH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2021
Last Update Date: 03/14/2021
Certification Date: 03/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6110 MAIN ST
LANHAM MD
20706-2749
US

IV. Provider business mailing address

6110 MAIN ST
LANHAM MD
20706-2749
US

V. Phone/Fax

Practice location:
  • Phone: 301-793-9605
  • Fax:
Mailing address:
  • Phone: 301-793-9605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: CHIDIADI B AGOH
Title or Position: PRESIDENT
Credential: PMHNP, FNP
Phone: 301-793-9605