Healthcare Provider Details

I. General information

NPI: 1164301198
Provider Name (Legal Business Name): CLETUS ALOT CHOFONG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2025
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12303 RONALD BEALL RD
UPPER MARLBORO MD
20774-5682
US

IV. Provider business mailing address

12303 RONALD BEALL RD
UPPER MARLBORO MD
20774-5682
US

V. Phone/Fax

Practice location:
  • Phone: 240-838-9559
  • Fax:
Mailing address:
  • Phone: 240-838-9559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCACII200001328
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: