Healthcare Provider Details

I. General information

NPI: 1316126121
Provider Name (Legal Business Name): FAMILY HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2007
Last Update Date: 12/07/2020
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3415 HAMILTON ST SUITE 9
HYATTSVILLE MD
20782-3953
US

IV. Provider business mailing address

3415 HAMILTON ST SUITE 9
HYATTSVILLE MD
20782-3953
US

V. Phone/Fax

Practice location:
  • Phone: 301-779-2461
  • Fax: 301-779-6095
Mailing address:
  • Phone: 301-779-2461
  • Fax: 301-779-6095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberLC0295
License Number StateMD

VIII. Authorized Official

Name: DR. BRUKE TADESSE
Title or Position: EXECUTIVE DIRECTOR
Credential: PSYD, LCPC, CAS
Phone: 301-779-2461