Provider Demographics
NPI:1376249110
Name:NKONG FOMANKA, DAVID (LGSW, LICSW)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:NKONG FOMANKA
Suffix:
Gender:M
Credentials:LGSW, LICSW
Other - Prefix:
Other - First Name:DAVID
Other - Middle Name:
Other - Last Name:FOMANKA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NKONG
Mailing Address - Street 1:7711 RIVERDALE RD APT 102
Mailing Address - Street 2:
Mailing Address - City:NEW CARROLLTON
Mailing Address - State:MD
Mailing Address - Zip Code:20784-3940
Mailing Address - Country:US
Mailing Address - Phone:443-985-7985
Mailing Address - Fax:
Practice Address - Street 1:4130 HUNT PL NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-3565
Practice Address - Country:US
Practice Address - Phone:202-651-1674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-03
Last Update Date:2024-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLG50083792104100000X
DCLC2000029671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC013255479Medicaid
DC072105216Medicaid