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General NPI Number Information
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NPI Number | 1861081002
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Entity Type | Organization
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Legal Business Name | KP OPTIMUM CARE BEHAVIORAL SERVICES
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Dates
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Enumeration Date | 01/12/2021
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Last Update Date | 01/12/2021
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Provider Practice Location Address
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Address Line | 370 MAIN ST
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City | LAUREL
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State | MD
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Zip | 20707-4133
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Country | US
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Telephone | 301-641-2284
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 114
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City | LAUREL
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State | MD
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Zip | 20725-0114
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | KATUMU FRANCES PETTIQUOI
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Credential | LCPC
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Telephone | 301-641-2284
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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