Healthcare Provider Details

I. General information

NPI: 1114449386
Provider Name (Legal Business Name): MR. ENOLA NASHOBA HASTIIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MR. DANIEL LOGAN DIXON

II. Dates (important events)

Enumeration Date: 07/10/2017
Last Update Date: 05/31/2026
Certification Date: 05/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10480 LITTLE PATUXENT PKWY
COLUMBIA MD
21044-3568
US

IV. Provider business mailing address

524 KENORA DR
MILLERSVILLE MD
21108-1317
US

V. Phone/Fax

Practice location:
  • Phone: 410-665-5776
  • Fax:
Mailing address:
  • Phone: 706-945-9776
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLC16487
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: