=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114463346
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUSTLINE TAH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2017
-----------------------------------------------------
Last Update Date | 05/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4017 MINNESOTA AVE NE
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20019-3541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-388-9202
-----------------------------------------------------
Fax | 202-388-4339
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 660 STREFORD WAY UNIT 210
-----------------------------------------------------
City | HYATTSVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20785-1234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-648-8594
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WP0809X
-----------------------------------------------------
Taxonomy Name | Adult Psychiatric/Mental Health Registered Nurse
-----------------------------------------------------
License Number | 500018807
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------