Basic Information
| Provider Information | |||||||||
| NPI: | 1801855697 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAHTEME SELASSIE, MDPA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MAHTEME SELASSIE, MDPA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 7910 WOODMONT AVE | ||||||||
| Address2: | SUITE 460 | ||||||||
| City: | BETHESDA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208143002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016569520 | ||||||||
| FaxNumber: | 3017183633 | ||||||||
| Practice Location | |||||||||
| Address1: | 7910 WOODMONT AVE | ||||||||
| Address2: | SUITE 460 | ||||||||
| City: | BETHESDA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208143002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016569520 | ||||||||
| FaxNumber: | 3017183633 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2006 | ||||||||
| LastUpdateDate: | 11/29/2007 | ||||||||
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| AuthorizedOfficialLastName: | SELASSIE | ||||||||
| AuthorizedOfficialFirstName: | MAHTEME | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3016569520 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | D0052686 | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | M44625 | 01 | MD | CDS | OTHER | D0052686 | 01 | MD | STATE LICENSE | OTHER |