Provider Demographics
NPI:1356002281
Name:WAKJIRA, KIDIST G
Entity Type:Individual
Prefix:MS
First Name:KIDIST
Middle Name:G
Last Name:WAKJIRA
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 1:9 BANKS AVE
Mailing Address - Street 2:
Mailing Address - City:MCADOO
Mailing Address - State:PA
Mailing Address - Zip Code:18237-2508
Mailing Address - Country:US
Mailing Address - Phone:888-726-4774
Mailing Address - Fax:
Practice Address - Street 1:9250 GAITHER RD
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-1420
Practice Address - Country:US
Practice Address - Phone:888-726-4774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-03
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician