Basic Information
| Provider Information | |||||||||
| NPI: | 1134482078 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KONCHOU | ||||||||
| FirstName: | IDA | ||||||||
| MiddleName: | MABELLE | ||||||||
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| Credential: | HHA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6731 NEW HAMPSHIRE AVE APT 409 | ||||||||
| Address2: | |||||||||
| City: | TAKOMA PARK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 209122801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2025450935 | ||||||||
| FaxNumber: | 2025450934 | ||||||||
| Practice Location | |||||||||
| Address1: | 6731 NEW HAMPSHIRE AVE APT 409 | ||||||||
| Address2: | |||||||||
| City: | TAKOMA PARK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 209122801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2025450935 | ||||||||
| FaxNumber: | 2025450934 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2012 | ||||||||
| LastUpdateDate: | 03/20/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | R207705 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.