Healthcare Provider Details

I. General information

NPI: 1164939385
Provider Name (Legal Business Name): ENRICHMENT ENDEAVORS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2018
Last Update Date: 01/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WEST RD
TOWSON MD
21204-2331
US

IV. Provider business mailing address

9114 OLD HARFORD RD
PARKVILLE MD
21234-2659
US

V. Phone/Fax

Practice location:
  • Phone: 443-750-3477
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number15603
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1750897088
Identifier TypeMEDICAID
Identifier StateMD
Identifier Issuer

VIII. Authorized Official

Name: KELLY DACUNHA
Title or Position: DIRECTOR
Credential: LCSW-C
Phone: 443-750-3477