Provider Demographics
NPI:1114449386
Name:HASTIIN, ENOLA NASHOBA
Entity Type:Individual
Prefix:MR
First Name:ENOLA
Middle Name:NASHOBA
Last Name:HASTIIN
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:DANIEL
Other - Middle Name:LOGAN
Other - Last Name:DIXON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:524 KENORA DR
Mailing Address - Street 2:
Mailing Address - City:MILLERSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21108-1317
Mailing Address - Country:US
Mailing Address - Phone:706-945-9776
Mailing Address - Fax:
Practice Address - Street 1:524 KENORA DR
Practice Address - Street 2:
Practice Address - City:MILLERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21108-1317
Practice Address - Country:US
Practice Address - Phone:706-945-9776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-10
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health