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General NPI Number Information
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NPI Number | 1316599012
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Entity Type | Individual
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Provider Name | MANGA OMASOMBO LGSW
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Gender | Female
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Dates
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Enumeration Date | 07/12/2019
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Last Update Date | 11/27/2023
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Provider Practice Location Address
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Address Line | 2616 MARTIN LUTHER KING JR AVE SE
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City | WASHINGTON
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State | DC
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Zip | 20020-7715
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Country | US
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Telephone | 202-724-7666
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Fax |
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Provider Business Mailing Address
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Address Line | 307 LANDING DR
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City | FREDERICKSBURG
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State | VA
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Zip | 22405-1264
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Country | US
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Telephone | 518-512-6220
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | LG50082208
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License Number State | DC
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