Provider Demographics
NPI:1518395714
Name:MAKONNEN, ROMAN
Entity Type:Individual
Prefix:
First Name:ROMAN
Middle Name:
Last Name:MAKONNEN
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 1:1200 1ST ST NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-3361
Mailing Address - Country:US
Mailing Address - Phone:202-442-5885
Mailing Address - Fax:
Practice Address - Street 1:1200 1ST ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-3361
Practice Address - Country:US
Practice Address - Phone:202-442-5885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-24
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC500794141041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool