Healthcare Provider Details

I. General information

NPI: 1437435393
Provider Name (Legal Business Name): DONNA TISH MPH, LGSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2011
Last Update Date: 10/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 CONNECTICUT AVE NW SUITE 300
WASHINGTON DC
20008-1158
US

IV. Provider business mailing address

4201 CONNECTICUT AVE NW SUITE 300
WASHINGTON DC
20008-1158
US

V. Phone/Fax

Practice location:
  • Phone: 202-624-0010
  • Fax: 202-624-0062
Mailing address:
  • Phone: 202-624-0010
  • Fax: 202-624-0062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLG50079468
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: