Healthcare Provider Details

I. General information

NPI: 1114463346
Provider Name (Legal Business Name): JUSTLINE TAH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2017
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4017 MINNESOTA AVE NE
WASHINGTON DC
20019-3541
US

IV. Provider business mailing address

660 STREFORD WAY UNIT 210
HYATTSVILLE MD
20785-1234
US

V. Phone/Fax

Practice location:
  • Phone: 202-388-9202
  • Fax: 202-388-4339
Mailing address:
  • Phone: 301-648-8594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number500018807
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: