Healthcare Provider Details

I. General information

NPI: 1366302820
Provider Name (Legal Business Name): LIFELONG SUPPORT INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2025
Last Update Date: 11/17/2025
Certification Date: 11/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14709 SUSAN MARIE WAY
WOODBINE MD
21797-8617
US

IV. Provider business mailing address

14709 SUSAN MARIE WAY
WOODBINE MD
21797-8617
US

V. Phone/Fax

Practice location:
  • Phone: 202-615-9100
  • Fax:
Mailing address:
  • Phone: 202-615-9100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: DR. NWANNE UMAZI UDEAGHA
Title or Position: EXECUTIVE PROGRAM DIRECTOR
Credential:
Phone: 202-615-9100