Healthcare Provider Details

I. General information

NPI: 1861081002
Provider Name (Legal Business Name): KP OPTIMUM CARE BEHAVIORAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2021
Last Update Date: 01/12/2021
Certification Date: 01/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

370 MAIN ST
LAUREL MD
20707-4133
US

IV. Provider business mailing address

PO BOX 114
LAUREL MD
20725-0114
US

V. Phone/Fax

Practice location:
  • Phone: 301-641-2284
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KATUMU FRANCES PETTIQUOI
Title or Position: CEO
Credential: LCPC
Phone: 301-641-2284