Healthcare Provider Details

I. General information

NPI: 1316599012
Provider Name (Legal Business Name): MANGA OMASOMBO LGSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2019
Last Update Date: 11/27/2023
Certification Date: 03/19/2021
Deactivation Date: 04/06/2020
Reactivation Date: 03/19/2021

III. Provider practice location address

2616 MARTIN LUTHER KING JR AVE SE
WASHINGTON DC
20020-7715
US

IV. Provider business mailing address

307 LANDING DR
FREDERICKSBURG VA
22405-1264
US

V. Phone/Fax

Practice location:
  • Phone: 202-724-7666
  • Fax:
Mailing address:
  • Phone: 518-512-6220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLG50082208
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: