Healthcare Provider Details

I. General information

NPI: 1497579114
Provider Name (Legal Business Name): ZEPHANIAH TITA TAKU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2024
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7005 E RIDGE DR
HYATTSVILLE MD
20785-4913
US

IV. Provider business mailing address

7005 E RIDGE DR
HYATTSVILLE MD
20785-4913
US

V. Phone/Fax

Practice location:
  • Phone: 240-729-0491
  • Fax:
Mailing address:
  • Phone: 240-877-8478
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: