Basic Information
Provider Information | |||||||||
NPI: | 1770755878 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KENNEDY KRIEGER EDUCATION AND COMMUNITY SERVICES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | KENNEDY KRIEGER SCHOOL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | P.O. BOX 744865 | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 30374 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4439231886 | ||||||||
FaxNumber: | 4439231895 | ||||||||
Practice Location | |||||||||
Address1: | 3825 GREENSPRING AVE. | ||||||||
Address2: | KENNEDY KRIEGER SCHOOL - HIGH SCHOOL | ||||||||
City: | BALTIMORE | ||||||||
State: | MD | ||||||||
PostalCode: | 21211 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4439239200 | ||||||||
FaxNumber: | 4439239405 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/28/2008 | ||||||||
LastUpdateDate: | 09/28/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NEUMAN | ||||||||
AuthorizedOfficialFirstName: | MIKE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT OF FINANCE | ||||||||
AuthorizedOfficialTelephone: | 4439231810 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/28/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041S0200X |   | MD | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | School | 163WC0400X |   | MD | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Case Management | 225100000X |   | MD | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   | 225X00000X |   | MD | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   | 235Z00000X |   | MD | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   | 261QD1600X | 30-036 | MD | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Developmental Disabilities |
ID Information
ID | Type | State | Issuer | Description | 1754815 01 | 05 | MD |   | MEDICAID |