Provider Demographics
NPI:1346723657
Name:MUDIMBI, ASSANI
Entity Type:Individual
Prefix:
First Name:ASSANI
Middle Name:
Last Name:MUDIMBI
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 1:7505 WILDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:TAKOMA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20912-7508
Mailing Address - Country:US
Mailing Address - Phone:301-501-0532
Mailing Address - Fax:
Practice Address - Street 1:5268 NICHOLSON LN # 188G
Practice Address - Street 2:
Practice Address - City:KENSINGTON
Practice Address - State:MD
Practice Address - Zip Code:20895-1009
Practice Address - Country:US
Practice Address - Phone:703-636-1703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-12
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician