Provider Demographics
NPI:1619529310
Name:MOLLA, TEWEDAJ KEBEDE
Entity Type:Individual
Prefix:
First Name:TEWEDAJ
Middle Name:KEBEDE
Last Name:MOLLA
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 1:5820 YORK RD STE 202
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21212-3620
Mailing Address - Country:US
Mailing Address - Phone:301-345-1022
Mailing Address - Fax:301-560-5588
Practice Address - Street 1:5820 YORK RD STE 202
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21212-3620
Practice Address - Country:US
Practice Address - Phone:301-345-1022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-12
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD25053104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD25053OtherMARYLAND BOARD OF SOCAIL WORK EXAMINERS