Healthcare Provider Details

I. General information

NPI: 1891051413
Provider Name (Legal Business Name): DIVINE FOMBU CSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2012
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13817 BRIARWOOD DR APT 1123
LAUREL MD
20708-1345
US

IV. Provider business mailing address

1706 HAMPSHIRE GREEN LN
SILVER SPRING MD
20903-2416
US

V. Phone/Fax

Practice location:
  • Phone: 240-476-3253
  • Fax:
Mailing address:
  • Phone: 202-545-0935
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: