Healthcare Provider Details

I. General information

NPI: 1427749985
Provider Name (Legal Business Name): BWANG FULE MARTHA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2023
Last Update Date: 06/05/2023
Certification Date: 06/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 METZEROTT RD APT 307
ADELPHI MD
20783-5104
US

IV. Provider business mailing address

14723 RING HOUSE RD
BRANDYWINE MD
20613-2042
US

V. Phone/Fax

Practice location:
  • Phone: 360-499-1307
  • Fax:
Mailing address:
  • Phone: 360-499-1307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: