Provider Demographics
NPI:1316599012
Name:OMASOMBO, MANGA (LGSW)
Entity Type:Individual
Prefix:
First Name:MANGA
Middle Name:
Last Name:OMASOMBO
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 LANDING DR
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22405-1264
Mailing Address - Country:US
Mailing Address - Phone:518-512-6220
Mailing Address - Fax:
Practice Address - Street 1:2616 MARTIN LUTHER KING JR AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-7715
Practice Address - Country:US
Practice Address - Phone:202-724-7666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-12
Last Update Date:2023-11-27
Deactivation Date:2020-04-06
Deactivation Code:
Reactivation Date:2021-03-19
Provider Licenses
StateLicense IDTaxonomies
DCLG50082208104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker