=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235683947
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WORK LIFE BEHAVIORAL HEALTH AND PROFESSIONAL TRAINING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2016
-----------------------------------------------------
Last Update Date | 10/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 795 AQUAHART RD STE 229
-----------------------------------------------------
City | GLEN BURNIE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21061-3958
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-487-6052
-----------------------------------------------------
Fax | 443-960-4203
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 795 AQUAHART RD STE 229
-----------------------------------------------------
City | GLEN BURNIE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21061-3958
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-487-6052
-----------------------------------------------------
Fax | 443-960-4203
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/SOCIAL WORKER
-----------------------------------------------------
Name | MRS. LATOYA MARIE NKONGOLO
-----------------------------------------------------
Credential | LCSW-C
-----------------------------------------------------
Telephone | 410-487-6052
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 19300
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------