Healthcare Provider Details

I. General information

NPI: 1023849379
Provider Name (Legal Business Name): KWASI BONSU OWUSU-AGYEMANG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2024
Last Update Date: 08/09/2024
Certification Date: 08/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 WHEELER RD SE
WASHINGTON DC
20032-4129
US

IV. Provider business mailing address

3787 MARY EVELYN WAY
ALEXANDRIA VA
22309-8230
US

V. Phone/Fax

Practice location:
  • Phone: 571-275-2638
  • Fax:
Mailing address:
  • Phone: 571-275-2638
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLGPC200001519
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: