Healthcare Provider Details

I. General information

NPI: 1174263222
Provider Name (Legal Business Name): CALVARY PSYCHIATRIC SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2022
Last Update Date: 05/30/2022
Certification Date: 05/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 MERCANTILE LN STE 243
UPPER MARLBORO MD
20774-5464
US

IV. Provider business mailing address

10609 BROADLEAF DR
UPPER MARLBORO MD
20774-2369
US

V. Phone/Fax

Practice location:
  • Phone: 240-761-3886
  • Fax:
Mailing address:
  • Phone: 240-761-3886
  • 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
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. OBINNA CHUKWUEBUKA OKONKWO
Title or Position: CEO
Credential: CRNP-PMH
Phone: 240-761-3886