=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790329530
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KENAH ONE HEALTH CARE SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2019
-----------------------------------------------------
Last Update Date | 02/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7310 RITCHIE HWY STE 612
-----------------------------------------------------
City | GLEN BURNIE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21061-3291
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-491-7854
-----------------------------------------------------
Fax | 443-288-4808
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7735 HOLLINS CHAPEL CT
-----------------------------------------------------
City | GLEN BURNIE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21060-8396
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-491-7854
-----------------------------------------------------
Fax | 443-288-4808
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | KULVINDER SINGH BASRA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 240-949-4886
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------