Provider Demographics
NPI:1164101374
Name:FOMBASON, MARIE YVONNE
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:YVONNE
Last Name:FOMBASON
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 1:11200 LOCKWOOD DR APT 302
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20901-4525
Mailing Address - Country:US
Mailing Address - Phone:202-985-8184
Mailing Address - Fax:
Practice Address - Street 1:915 RHODE ISLAND AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20001-4153
Practice Address - Country:US
Practice Address - Phone:301-458-9469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-14
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker