Provider Demographics
NPI:1194354290
Name:IKUBISEHIN, RACHEAL S
Entity type:Individual
Prefix:
First Name:RACHEAL
Middle Name:S
Last Name:IKUBISEHIN
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 1:7800 WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:PARKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21234-5825
Mailing Address - Country:US
Mailing Address - Phone:443-824-5678
Mailing Address - Fax:
Practice Address - Street 1:7800 WILSON AVE
Practice Address - Street 2:
Practice Address - City:PARKVILLE
Practice Address - State:MD
Practice Address - Zip Code:21234-5825
Practice Address - Country:US
Practice Address - Phone:443-824-5678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-02
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD4108893000Medicaid