=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790345270
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GILGAL GROUP PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2019
-----------------------------------------------------
Last Update Date | 06/18/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5205 EAST DR STE H
-----------------------------------------------------
City | ARBUTUS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21227-2403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-631-3878
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5205 EAST DR STE H
-----------------------------------------------------
City | ARBUTUS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21227-2403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-631-3878
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/PROGRAM ADMINISTRATOR
-----------------------------------------------------
Name | DR. FREDERICK OLUMIDE KUMOLALO
-----------------------------------------------------
Credential | LMSW, PHD
-----------------------------------------------------
Telephone | 443-631-3878
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------