Healthcare Provider Details

I. General information

NPI: 1548164411
Provider Name (Legal Business Name): ERIC MBIONYI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9975 CAMPUS WAY S
LARGO MD
20774-2151
US

IV. Provider business mailing address

9975 CAMPUS WAY S
LARGO MD
20774-2151
US

V. Phone/Fax

Practice location:
  • Phone: 410-215-4674
  • Fax: 410-215-4674
Mailing address:
  • Phone: 410-215-4674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number81885442
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: