Healthcare Provider Details

I. General information

NPI: 1528805231
Provider Name (Legal Business Name): EYOB HABTEMICHAEL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2024
Last Update Date: 07/05/2026
Certification Date: 07/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9994 SOWDER VILLAGE SQ # 102
MANASSAS VA
20109-5464
US

IV. Provider business mailing address

7108 S KANNER HWY
STUART FL
34997-7462
US

V. Phone/Fax

Practice location:
  • Phone: 185-583-2672
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: