Provider Demographics
NPI:1467082354
Name:MOKUBA, ODETTE
Entity Type:Individual
Prefix:
First Name:ODETTE
Middle Name:
Last Name:MOKUBA
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 1:709 HUDSON AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:TAKOMA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20912-6817
Mailing Address - Country:US
Mailing Address - Phone:240-486-7333
Mailing Address - Fax:
Practice Address - Street 1:709 HUDSON AVE APT 3
Practice Address - Street 2:
Practice Address - City:TAKOMA PARK
Practice Address - State:MD
Practice Address - Zip Code:20912-6817
Practice Address - Country:US
Practice Address - Phone:240-486-7333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-20
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA101YM0800X, 376K00000X
101YM0800X, 101YP1600X
VA1401191138376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral