Healthcare Provider Details

I. General information

NPI: 1548715303
Provider Name (Legal Business Name): ELISABETH OBANDO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2016
Last Update Date: 08/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

248 STEVENSON SQ
ALEXANDRIA VA
22304-3510
US

IV. Provider business mailing address

248 STEVENSON SQ
ALEXANDRIA VA
22304-3510
US

V. Phone/Fax

Practice location:
  • Phone: 817-659-8969
  • Fax:
Mailing address:
  • Phone: 817-659-8969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP001053
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: