Provider Demographics
NPI:1336676212
Name:TABULA RASA DOMESTIC VIOLENCE INC
Entity Type:Organization
Organization Name:TABULA RASA DOMESTIC VIOLENCE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:AVA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-217-8442
Mailing Address - Street 1:13017 WISTERIA DR # 172
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20874-2621
Mailing Address - Country:US
Mailing Address - Phone:240-217-8442
Mailing Address - Fax:
Practice Address - Street 1:4325 FORBES BLVD STE C
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-4856
Practice Address - Country:US
Practice Address - Phone:240-217-8442
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-22
Last Update Date:2017-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management