Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101YA0400X | Addiction Counselor (Substance Use Disorder) | ||
N | 103TA0700X | Adult Development & Aging Psychologist | ||
N | 103TH0004X | Health Psychologist | ||
N | 103TH0100X | Health Service |
NPI | 1245611664 |
---|---|
Provider Name | Seble Wongel Dejene |
First Address | Reston, VA 20191-5481 |
Second Address | Reston, VA 20191-5481 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/06/2015 |
Last Update Date | 11/06/2015 |