Provider Demographics
NPI:1083911762
Name:IJOMAH, BENEDICT C (LCSW-C)
Entity Type:Individual
Prefix:
First Name:BENEDICT
Middle Name:C
Last Name:IJOMAH
Suffix:
Gender:M
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4607 69TH AVE
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20784-2123
Mailing Address - Country:US
Mailing Address - Phone:301-386-0014
Mailing Address - Fax:301-386-0018
Practice Address - Street 1:4607 69TH AVE
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20784-2123
Practice Address - Country:US
Practice Address - Phone:301-386-0014
Practice Address - Fax:301-386-0018
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-16
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD09832101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health