Basic Information
| Provider Information | |||||||||
| NPI: | 1275849457 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DC GOVERNMENT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | DEPARTMENT OF MENTAL HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 821 HOWARD RD SE | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200205805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2026981838 | ||||||||
| FaxNumber: | 2026982466 | ||||||||
| Practice Location | |||||||||
| Address1: | 821 HOWARD RD SE | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200205805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2026981838 | ||||||||
| FaxNumber: | 2026982466 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2010 | ||||||||
| LastUpdateDate: | 08/25/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOWDEN | ||||||||
| AuthorizedOfficialFirstName: | SHERMAIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2026981829 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PARENT INFANT EARLY CHILDHOOD ENHANCEMENT PROGRAM | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 536001131 | 05 | DC | MEDICAID |