Provider Demographics
NPI:1457160400
Name:MBAH, KINGSLY
Entity type:Individual
Prefix:
First Name:KINGSLY
Middle Name:
Last Name:MBAH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3205 WINTER PARK CT
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-7550
Mailing Address - Country:US
Mailing Address - Phone:405-650-8607
Mailing Address - Fax:
Practice Address - Street 1:3205 WINTER PARK CT
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20774-7550
Practice Address - Country:US
Practice Address - Phone:405-650-8607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-04
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC171M00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator