Basic Information
| Provider Information | |||||||||
| NPI: | 1831597871 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KENNEDY KRIEGER EDUCATION AND COMMUNITY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KENNEDY KRIEGER SCHOOL (CENTRAL HIGH SCHOOL) | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 744865 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4439231886 | ||||||||
| FaxNumber: | 4439231895 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 CABIN BRANCH RD. | ||||||||
| Address2: | |||||||||
| City: | CAPITAL HEIGHTS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 20743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4439239200 | ||||||||
| FaxNumber: | 4439231875 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2014 | ||||||||
| LastUpdateDate: | 09/16/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NEUMAN | ||||||||
| AuthorizedOfficialFirstName: | MIKE | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 4439231810 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041S0200X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | School | 163WC0400X | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Case Management | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 235Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 261Q00000X | 30-036 | MD | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 1754815 01 | 05 | MD | MEDICAID |