Provider Demographics
NPI:1033812086
Name:FOFANAH, EDWARD BRIMA
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:BRIMA
Last Name:FOFANAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4921 SEMINARY RD APT 328
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22311-1804
Mailing Address - Country:US
Mailing Address - Phone:571-635-2526
Mailing Address - Fax:
Practice Address - Street 1:2124 MARTIN LUTHER KING JR AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-5732
Practice Address - Country:US
Practice Address - Phone:202-563-7632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-27
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251S00000XAgenciesCommunity/Behavioral Health