Healthcare Provider Details

I. General information

NPI: 1386317683
Provider Name (Legal Business Name): TAHJA-RAE M DICKENSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2021
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12410 MILESTONE CENTER DR STE 600
GERMANTOWN MD
20876-7102
US

IV. Provider business mailing address

12410 MILESTONE CENTER DR STE 600
GERMANTOWN MD
20876-7102
US

V. Phone/Fax

Practice location:
  • Phone: 571-457-9306
  • Fax:
Mailing address:
  • Phone: 571-457-9306
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number119359
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number29901
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW027072
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904019866
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: