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General NPI Number Information
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NPI Number | 1558893586
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Entity Type | Organization
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Legal Business Name | MAKONNEN THERAPEUTIC SERVICES
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Dates
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Enumeration Date | 03/29/2017
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Last Update Date | 03/29/2017
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Provider Practice Location Address
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Address Line | 881 FLAGLER DR
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City | GAITHERSBURG
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State | MD
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Zip | 20878-1968
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Country | US
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Telephone | 410-422-3386
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Fax |
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Provider Business Mailing Address
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Address Line | 881 FLAGLER DR
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City | GAITHERSBURG
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State | MD
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Zip | 20878-1968
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Country | US
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Telephone | 410-422-3386
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MS. RAEJON LYNNE MAKONNEN
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Credential |
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Telephone | 410-422-3386
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | LC7426
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License Number State | MD
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