Healthcare Provider Details

I. General information

NPI: 1144014226
Provider Name (Legal Business Name): CAMPHIRE INITIATIVE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2025
Last Update Date: 04/05/2025
Certification Date: 04/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14440 CHERRY LANE CT STE 102
LAUREL MD
20707-4946
US

IV. Provider business mailing address

1031 RAILBED DR
ODENTON MD
21113-3733
US

V. Phone/Fax

Practice location:
  • Phone: 202-763-2409
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: YETUNDE ODOLE
Title or Position: PMHNP
Credential:
Phone: 202-763-2409