Healthcare Provider Details

I. General information

NPI: 1114859097
Provider Name (Legal Business Name): ANTOINETTE HAZUMUTIMA BANGAMWABO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2026
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9622 WESHIRE DR
UPPER MARLBORO MD
20774-2701
US

IV. Provider business mailing address

9622 WESHIRE DR
UPPER MARLBORO MD
20774-2701
US

V. Phone/Fax

Practice location:
  • Phone: 202-240-7213
  • Fax:
Mailing address:
  • Phone: 202-240-7213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberHAA200006277
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: