Provider Demographics
NPI:1003498817
Name:KEBEDE, MIRAF SR
Entity Type:Individual
Prefix:
First Name:MIRAF
Middle Name:
Last Name:KEBEDE
Suffix:SR
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 E WEST HWY APT 711
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-6275
Mailing Address - Country:US
Mailing Address - Phone:240-476-6676
Mailing Address - Fax:
Practice Address - Street 1:4130 HUNT PL NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-3565
Practice Address - Country:US
Practice Address - Phone:202-388-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-22
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD25711104100000X
DCLG50082914104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD46905567200Medicaid