Provider Demographics
NPI:1245611664
Name:DEJENE, SEBLE WONGEL
Entity Type:Individual
Prefix:
First Name:SEBLE
Middle Name:WONGEL
Last Name:DEJENE
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 1:1801 ROBERT FULTON DR STE 480
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20191-5481
Mailing Address - Country:US
Mailing Address - Phone:703-261-7000
Mailing Address - Fax:703-860-1040
Practice Address - Street 1:1801 ROBERT FULTON DR STE 480
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191-5481
Practice Address - Country:US
Practice Address - Phone:703-261-7000
Practice Address - Fax:703-860-1040
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-11
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service