Healthcare Provider Details

I. General information

NPI: 1366208258
Provider Name (Legal Business Name): KOUEKAM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2024
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7610 CARROLL AVE STE 260
TAKOMA PARK MD
20912-6302
US

IV. Provider business mailing address

11973 BELTSVILLE DR
BELTSVILLE MD
20705-4004
US

V. Phone/Fax

Practice location:
  • Phone: 240-581-2625
  • Fax:
Mailing address:
  • Phone: 240-581-2625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: DORIS TIOKO
Title or Position: PROVIDER
Credential:
Phone: 240-581-2625