Healthcare Provider Details

I. General information

NPI: 1942738133
Provider Name (Legal Business Name): LINDA OWUSUAA IYEBOTE LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LINDA NSIAH LGSW

II. Dates (important events)

Enumeration Date: 06/01/2017
Last Update Date: 06/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6019 ARCHSTONE WAY APT 401
ALEXANDRIA VA
22310-5526
US

IV. Provider business mailing address

6019 ARCHSTONE WAY APT 401
ALEXANDRIA VA
22310-5526
US

V. Phone/Fax

Practice location:
  • Phone: 703-300-6473
  • Fax:
Mailing address:
  • Phone: 703-300-6473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLG50081492
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number21638
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC50082015
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: