Healthcare Provider Details

I. General information

NPI: 1730929217
Provider Name (Legal Business Name): TABETH AGHAJI-ENWEREMADU LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2024
Last Update Date: 05/30/2024
Certification Date: 05/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3331 DUKE ST
ALEXANDRIA VA
22314-4597
US

IV. Provider business mailing address

20 FAWN HILL RD
TUXEDO PARK NY
10987-3514
US

V. Phone/Fax

Practice location:
  • Phone: 703-552-2722
  • Fax:
Mailing address:
  • Phone: 516-996-7805
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0903004173
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: