=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124961362
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SERENO CLINIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2026
-----------------------------------------------------
Last Update Date | 04/13/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3713 DECATUR AVE
-----------------------------------------------------
City | KENSINGTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20895-2105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-922-4301
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3717 DECATUR AVE STE 3
-----------------------------------------------------
City | KENSINGTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20895-2148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-922-4301
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AGENT
-----------------------------------------------------
Name | MELANIE MIKSOVSKY
-----------------------------------------------------
Credential | NA
-----------------------------------------------------
Telephone | 443-510-0456
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------