MEDICARE: AUTHENTIC MENTAL WELLNESS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1801573605
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AUTHENTIC MENTAL WELLNESS LLC

Provider Business Mailing Address
First Line	:	10810 DARNESTOWN RD STE 103
Second Line	:
City	:	GAITHERSBURG
State	:	MD
Zip	:	20878-2604
Country	:	US
Telephone Number	:	240-829-1863
Fax Number	:	240-238-6187

Provider Business Practice Location Address
First Line	:	10810 DARNESTOWN RD STE 103
Second Line	:
City	:	GAITHERSBURG
State	:	MD
Zip	:	20878-2604
Country	:	US
Telephone Number	:	240-829-1863
Fax Number	:	240-238-6187

Authorized Official
Title or Position	:	PROVIDER
Name	:	FRANCINE KAMHOUA
Credential	:
Telephone Number	:	703-508-6182

Provider Enumeration Date	:	07/03/2023
Last Update Date	:	11/14/2024

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