Provider Demographics
NPI:1750904314
Name:KINGDOM BEHAVIORAL HEALTH LLC
Entity type:Organization
Organization Name:KINGDOM BEHAVIORAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESISENT/ CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:TAOFEEK
Authorized Official - Middle Name:
Authorized Official - Last Name:BELLO
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE PRACTITIONER
Authorized Official - Phone:240-284-4641
Mailing Address - Street 1:5 PUBLIC SQ STE 213
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-5599
Mailing Address - Country:US
Mailing Address - Phone:240-284-4641
Mailing Address - Fax:240-284-4671
Practice Address - Street 1:5 PUBLIC SQ STE 213
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-5599
Practice Address - Country:US
Practice Address - Phone:240-284-4641
Practice Address - Fax:240-284-4671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-18
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD007559100Medicaid