Healthcare Provider Details

I. General information

NPI: 1033583463
Provider Name (Legal Business Name): ATEFEH FATHNEZHAD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2015
Last Update Date: 12/10/2025
Certification Date: 11/29/2022
Deactivation Date: 11/29/2022
Reactivation Date: 12/10/2025

III. Provider practice location address

12212 WALNUT CREEK CT
GERMANTOWN MD
20874-1570
US

IV. Provider business mailing address

12212 WALNUT CREEK CT
GERMANTOWN MD
20874-1570
US

V. Phone/Fax

Practice location:
  • Phone: 240-780-8508
  • Fax:
Mailing address:
  • Phone: 240-780-8508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number20251
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: