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General NPI Number Information
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NPI Number | 1417489295
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Entity Type | Organization
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Legal Business Name | SEPPK
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Dates
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Enumeration Date | 03/30/2017
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Last Update Date | 03/30/2017
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Provider Practice Location Address
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Address Line | 1224 W OLD LIBERTY RD
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City | SYKESVILLE
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State | MD
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Zip | 21784-9327
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Country | US
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Telephone | 410-875-7284
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Fax | 410-875-7284
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Provider Business Mailing Address
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Address Line | 1224 W OLD LIBERTY RD
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City | SYKESVILLE
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State | MD
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Zip | 21784-9327
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Country | US
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Telephone | 410-875-7284
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Fax | 410-875-7284
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Authorized Official
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Title or Position | THERAPSIT
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Name | PROF. DEUK B KONG
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Credential | LMT
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Telephone | 410-875-7284
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320700000X
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Taxonomy Name | Physical Disabilities Residential Treatment Facility
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License Number | M05267
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License Number State | MD
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