Basic Information
Provider Information | |||||||||
NPI: | 1629470547 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HEFUNA MENTAL HEALTH WELLNESS LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 16220 FREDERICK RD | ||||||||
Address2: | SUITE 310 | ||||||||
City: | GAITHERSBURG | ||||||||
State: | MD | ||||||||
PostalCode: | 208774039 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3013451022 | ||||||||
FaxNumber: | 3015605557 | ||||||||
Practice Location | |||||||||
Address1: | 16220 FREDERICK RD | ||||||||
Address2: | SUITE 310 | ||||||||
City: | GAITHERSBURG | ||||||||
State: | MD | ||||||||
PostalCode: | 208774039 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3013451022 | ||||||||
FaxNumber: | 3015605557 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/23/2014 | ||||||||
LastUpdateDate: | 09/23/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HEFUNA | ||||||||
AuthorizedOfficialFirstName: | AHMED | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PSYCHIATRIST | ||||||||
AuthorizedOfficialTelephone: | 3013451022 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | D66576 | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
ID | Type | State | Issuer | Description | D66576 | 01 | MD | MD LICENSE | OTHER |