Healthcare Provider Details

I. General information

NPI: 1932942125
Provider Name (Legal Business Name): ROGER SERGES TCHOUASSI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2024
Last Update Date: 05/19/2025
Certification Date: 05/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4302 DAY LILY DR
BOWIE MD
20720-4241
US

IV. Provider business mailing address

12281 REVOLUTION CT
WALDORF MD
20602-4226
US

V. Phone/Fax

Practice location:
  • Phone: 240-688-5875
  • Fax:
Mailing address:
  • Phone: 240-688-5875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: