Provider Demographics
NPI:1306861752
Name:TADESSE, BRUKE
Entity Type:Individual
Prefix:DR
First Name:BRUKE
Middle Name:
Last Name:TADESSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3415 HAMILTON ST STE 9
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20782-3953
Mailing Address - Country:US
Mailing Address - Phone:301-779-2461
Mailing Address - Fax:301-779-6095
Practice Address - Street 1:3415 HAMILTON ST STE 9
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20782
Practice Address - Country:US
Practice Address - Phone:301-779-2461
Practice Address - Fax:301-779-6095
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2019-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC0295103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1316126121Medicaid
MD1093750697Medicaid