Basic Information
| Provider Information | |||||||||
| NPI: | 1225034135 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SELASSIE | ||||||||
| FirstName: | MAHTEME | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7910 WOODMONT AVE | ||||||||
| Address2: | STE 460 | ||||||||
| City: | BETHESDA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208143066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3019348811 | ||||||||
| FaxNumber: | 3019349321 | ||||||||
| Practice Location | |||||||||
| Address1: | 7910 WOODMONT AVE | ||||||||
| Address2: | STE 460 | ||||||||
| City: | BETHESDA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208143066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3019348811 | ||||||||
| FaxNumber: | 3019349321 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/16/2006 | ||||||||
| NPIReactivationDate: | 03/21/2006 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 04944 | MD | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 567898 | 01 | MD | NCPPO | OTHER | 141971 | 01 | MD | VALUE OPTIONS | OTHER | M5790001 | 01 | DC | BLUE CROSS | OTHER | 2129679 | 01 | MD | MAMSI/ALLIANCE | OTHER | 583BMA | 01 | MD | BLUE CROSS | OTHER |