=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639671910
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MY BROTHER'S KEEPER TRANSITIONAL LIVING SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2018
-----------------------------------------------------
Last Update Date | 03/02/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1390 KENYON ST NW APT 614
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20010-7227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-246-5568
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1390 KENYON ST NW APT 614
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20010-7227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-246-5568
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | EBONY WASHINGTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 202-386-6311
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------