=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437960143
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MUTAILIFU LUTUBULA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2025
-----------------------------------------------------
Last Update Date | 01/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11720 BELTSVILLE DR STE 500A15
-----------------------------------------------------
City | BELTSVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20705-3166
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-790-8903
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1771 N PIERCE ST APT 2503
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22209-1871
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-305-9549
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------