Provider Demographics
NPI:1861081002
Name:KP OPTIMUM CARE BEHAVIORAL SERVICES
Entity type:Organization
Organization Name:KP OPTIMUM CARE BEHAVIORAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KATUMU
Authorized Official - Middle Name:FRANCES
Authorized Official - Last Name:PETTIQUOI
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:301-641-2284
Mailing Address - Street 1:PO BOX 114
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20725-0114
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:370 MAIN ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-4133
Practice Address - Country:US
Practice Address - Phone:301-641-2284
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health