Provider Demographics
NPI:1093369654
Name:MEKONNEN, MAHLET
Entity Type:Individual
Prefix:
First Name:MAHLET
Middle Name:
Last Name:MEKONNEN
Suffix:
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 1:5465 N MORGAN ST APT 202
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22312-3325
Mailing Address - Country:US
Mailing Address - Phone:703-944-1726
Mailing Address - Fax:
Practice Address - Street 1:1900 N BEAUREGARD ST STE 200
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22311-1727
Practice Address - Country:US
Practice Address - Phone:703-746-6004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-31
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040106641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical