Healthcare Provider Details

I. General information

NPI: 1609403849
Provider Name (Legal Business Name): SHAJAVA SHEVOUGNE MILLER CAC-II
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2020
Last Update Date: 03/26/2020
Certification Date: 03/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 2ND ST NW STE 2NORTH
WASHINGTON DC
20001-2003
US

IV. Provider business mailing address

425 2ND ST NW STE 2NORTH
WASHINGTON DC
20001-2003
US

V. Phone/Fax

Practice location:
  • Phone: 202-783-7343
  • Fax:
Mailing address:
  • Phone: 202-783-7343
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1278
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: