Provider Demographics
NPI:1629505367
Name:OBENG, CARLLISTUS (MED)
Entity Type:Individual
Prefix:
First Name:CARLLISTUS
Middle Name:
Last Name:OBENG
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8671 HAYSHED LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-2620
Mailing Address - Country:US
Mailing Address - Phone:410-908-1365
Mailing Address - Fax:
Practice Address - Street 1:6200 KANSAS AVE NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20011-1508
Practice Address - Country:US
Practice Address - Phone:202-722-4421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-12
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool