Healthcare Provider Details

I. General information

NPI: 1629505367
Provider Name (Legal Business Name): CARLLISTUS OBENG M.ED
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2017
Last Update Date: 05/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 KANSAS AVE NE
WASHINGTON DC
20011-1508
US

IV. Provider business mailing address

8671 HAYSHED LN
COLUMBIA MD
21045-2620
US

V. Phone/Fax

Practice location:
  • Phone: 202-722-4421
  • Fax:
Mailing address:
  • Phone: 410-908-1365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: