Healthcare Provider Details

I. General information

NPI: 1386879955
Provider Name (Legal Business Name): 11714 TUSCANY DRIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2009
Last Update Date: 05/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11714 TUSCANY DR
LAUREL MD
20708-2841
US

IV. Provider business mailing address

11714 TUSCANY DR
LAUREL MD
20708-2841
US

V. Phone/Fax

Practice location:
  • Phone: 301-332-7222
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: NGOZI MARYANN OKUDOH
Title or Position: ADMINISTRATOR
Credential:
Phone: 301-332-7222