Provider Demographics
NPI:1073162103
Name:KREAL, BAMBII (CAC-AD)
Entity Type:Individual
Prefix:
First Name:BAMBII
Middle Name:
Last Name:KREAL
Suffix:
Gender:F
Credentials:CAC-AD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45980 E QUINCY TER
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20653-6328
Mailing Address - Country:US
Mailing Address - Phone:609-313-2656
Mailing Address - Fax:
Practice Address - Street 1:21770 FRANKLIN DELANO ROOSEVELT BLVD
Practice Address - Street 2:
Practice Address - City:LEXINGTON PARK
Practice Address - State:MD
Practice Address - Zip Code:20653
Practice Address - Country:US
Practice Address - Phone:301-997-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-11
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC2733101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)