Healthcare Provider Details

I. General information

NPI: 1386487643
Provider Name (Legal Business Name): MIVA MENTAL HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2024
Last Update Date: 09/27/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1614 NORDIC HILL CIR
SILVER SPRING MD
20906-5927
US

IV. Provider business mailing address

1614 NORDIC HILL CIR
SILVER SPRING MD
20906-5927
US

V. Phone/Fax

Practice location:
  • Phone: 409-356-9778
  • Fax:
Mailing address:
  • Phone: 409-356-9778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: AKOUVI DZIGBODI AMOUZOUVI-ABA
Title or Position: OWNER
Credential: NP
Phone: 409-356-9778