Healthcare Provider Details

I. General information

NPI: 1770890378
Provider Name (Legal Business Name): KINDRED COLLABORATIVE RESOURCES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2010
Last Update Date: 09/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 MERCANTILE LN SUITE 124 B & C
LARGO MD
20774-5327
US

IV. Provider business mailing address

1300 MERCANTILE LN SUITE 124 B & C
LARGO MD
20774-5327
US

V. Phone/Fax

Practice location:
  • Phone: 301-563-9833
  • Fax: 301-563-9834
Mailing address:
  • Phone: 301-563-9833
  • Fax: 301-563-9834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT870165
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT010000578
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP000207
License Number StateDC

VIII. Authorized Official

Name: ANNA M DELGADO
Title or Position: CEO
Credential: MA-SLP
Phone: 301-563-9833