Healthcare Provider Details

I. General information

NPI: 1144905456
Provider Name (Legal Business Name): DONWILLIAM ENOHTAH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2023
Last Update Date: 08/04/2023
Certification Date: 08/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9979 GOOD LUCK RD
LANHAM MD
20706-3282
US

IV. Provider business mailing address

9979 GOOD LUCK RD
LANHAM MD
20706-3282
US

V. Phone/Fax

Practice location:
  • Phone: 240-917-7561
  • Fax:
Mailing address:
  • Phone: 240-917-7561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: