=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669161782
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KALEIDOSCOPE WELLNESS AND EDUCATION GROUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2023
-----------------------------------------------------
Last Update Date | 09/28/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14935 NIGHTHAWK LN
-----------------------------------------------------
City | BOWIE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20716-1036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-202-4353
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14935 NIGHTHAWK LN
-----------------------------------------------------
City | BOWIE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20716-1036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-202-4353
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KENYA COLEMAN
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 301-202-4353
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------