Healthcare Provider Details

I. General information

NPI: 1619887965
Provider Name (Legal Business Name): KENAH ONE HEALTH CARE SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2026
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11130 FAIRFAX BLVD STE 202
FAIRFAX VA
22030-5035
US

IV. Provider business mailing address

11130 FAIRFAX BLVD STE 202
FAIRFAX VA
22030-5035
US

V. Phone/Fax

Practice location:
  • Phone: 443-465-9958
  • Fax:
Mailing address:
  • Phone: 443-465-9958
  • 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: KETTY M NGONA
Title or Position: CEO
Credential:
Phone: 443-465-9958