Provider Demographics
NPI:1598523359
Name:ICHILE-MCKENZIE, ONGISA
Entity Type:Individual
Prefix:
First Name:ONGISA
Middle Name:
Last Name:ICHILE-MCKENZIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6675 POMFRET RD
Mailing Address - Street 2:
Mailing Address - City:LA PLATA
Mailing Address - State:MD
Mailing Address - Zip Code:20646-5808
Mailing Address - Country:US
Mailing Address - Phone:240-640-9577
Mailing Address - Fax:
Practice Address - Street 1:1401 MERCANTILE LN STE 543
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20774-4328
Practice Address - Country:US
Practice Address - Phone:240-696-4198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-07
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist