=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104705771
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KCM RESIDENTIAL CARE SOULTIONS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2025
-----------------------------------------------------
Last Update Date | 08/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30 PRESTBURY SQ STE 322
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19713-3237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-295-1098
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30 PRESTBURY SQ STE 322
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19713-3237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | CRYSTAL AMOAH
-----------------------------------------------------
Credential | PMHNP-BC
-----------------------------------------------------
Telephone | 484-620-5677
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------