Healthcare Provider Details

I. General information

NPI: 1255635850
Provider Name (Legal Business Name): KENYA MATTOX MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2010
Last Update Date: 10/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 KENNEDY ST NW 14
WASHINGTON DC
20011-3096
US

IV. Provider business mailing address

715 KENNEDY ST NW 14
WASHINGTON DC
20011-3096
US

V. Phone/Fax

Practice location:
  • Phone: 301-332-8028
  • Fax:
Mailing address:
  • Phone: 301-332-8028
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number15847
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberLG50079423
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: