Healthcare Provider Details

I. General information

NPI: 1336858422
Provider Name (Legal Business Name): HOLY MBAH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2022
Last Update Date: 06/01/2023
Certification Date: 06/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6305 61ST PL
RIVERDALE MD
20737-1408
US

IV. Provider business mailing address

6305 61ST PL
RIVERDALE MD
20737-1408
US

V. Phone/Fax

Practice location:
  • Phone: 202-560-0475
  • Fax:
Mailing address:
  • Phone: 202-560-0475
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: