Healthcare Provider Details

I. General information

NPI: 1164190898
Provider Name (Legal Business Name): MAJDOLEEN MARIE ALTAHTAMONI QMHS 3YRS CMS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2021
Last Update Date: 05/01/2023
Certification Date: 05/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5439 BURKHARDT RD
DAYTON OH
45431-2111
US

IV. Provider business mailing address

434 EASTLAND RD
BEREA OH
44017-1217
US

V. Phone/Fax

Practice location:
  • Phone: 937-791-1440
  • Fax:
Mailing address:
  • Phone: 440-234-2006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: