Healthcare Provider Details

I. General information

NPI: 1518204999
Provider Name (Legal Business Name): PRODIGY STUDENT SUPPORT SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2013
Last Update Date: 01/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2351 24TH ST SE 1827
WASHINGTON DC
20020-3426
US

IV. Provider business mailing address

2351 24TH ST SE 1827
WASHINGTON DC
20020-3426
US

V. Phone/Fax

Practice location:
  • Phone: 202-510-4192
  • Fax:
Mailing address:
  • Phone: 202-510-4192
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberPRC14292
License Number StateDC

VIII. Authorized Official

Name: FREEDOM SADIQ DOWDY
Title or Position: FOUNDER/CHIEF EXECUTIVE OFFICER
Credential: LPC
Phone: 202-510-4192