Provider Demographics
NPI:1952008880
Name:ACTIVISION FIDELITY PSYCHIATRIC MENTAL HEALTH LLC
Entity Type:Organization
Organization Name:ACTIVISION FIDELITY PSYCHIATRIC MENTAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:AMANZE
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP-PMH
Authorized Official - Phone:301-907-1199
Mailing Address - Street 1:2409 BAIKAL LOOP
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-7051
Mailing Address - Country:US
Mailing Address - Phone:301-907-1199
Mailing Address - Fax:
Practice Address - Street 1:2409 BAIKAL LOOP
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20774-7051
Practice Address - Country:US
Practice Address - Phone:301-907-1199
Practice Address - Fax:240-342-3440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-10
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty