=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114168341
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDICAL FACULTY ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2009
-----------------------------------------------------
Last Update Date | 03/18/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2150 PENNSYLVANIA AVE NW SUITE 10-407
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20037-3201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-741-3375
-----------------------------------------------------
Fax | 202-741-3396
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2150 PENNSYLVANIA AVE NW SUITE 10-407
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20037-3201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-741-3375
-----------------------------------------------------
Fax | 202-741-3396
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROGRAM DIRECTOR
-----------------------------------------------------
Name | MISS MARK TATELBAUM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 202-741-3375
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PSY1672
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------