=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508631375
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SERENITY PSYCHIATRIC AND MENTAL HEALTH SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2023
-----------------------------------------------------
Last Update Date | 01/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12800 MIDDLEBROOK RD STE 400
-----------------------------------------------------
City | GERMANTOWN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20874-5282
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-812-4540
-----------------------------------------------------
Fax | 301-812-4540
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13017 WISTERIA DR STE 114
-----------------------------------------------------
City | GERMANTOWN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20874-2621
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-812-4540
-----------------------------------------------------
Fax | 301-238-7850
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | HENRIETTA SAGOE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 301-812-4540
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------