Provider Demographics
NPI:1164116737
Name:FORNAH, FATU
Entity Type:Individual
Prefix:
First Name:FATU
Middle Name:
Last Name:FORNAH
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 1:303 MARSHALLS VENTURE CT
Mailing Address - Street 2:
Mailing Address - City:ACCOKEEK
Mailing Address - State:MD
Mailing Address - Zip Code:20607-3347
Mailing Address - Country:US
Mailing Address - Phone:703-991-9553
Mailing Address - Fax:703-997-5971
Practice Address - Street 1:2000 N BEAUREGARD ST APT 115
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22311-4633
Practice Address - Country:US
Practice Address - Phone:703-991-9553
Practice Address - Fax:703-997-5971
Is Sole Proprietor?:No
Enumeration Date:2023-06-06
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA437701001103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities