Provider Demographics
NPI:1720589542
Name:BANDONG, WILMA EVANGELINE ABUDA (DDA SERVICE PROVIDER)
Entity Type:Individual
Prefix:
First Name:WILMA EVANGELINE
Middle Name:ABUDA
Last Name:BANDONG
Suffix:
Gender:F
Credentials:DDA SERVICE PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3060 MITCHELLVILLE RD STE 104
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-3963
Mailing Address - Country:US
Mailing Address - Phone:202-460-6219
Mailing Address - Fax:
Practice Address - Street 1:3060 MITCHELLVILLE RD STE 104
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-3963
Practice Address - Country:US
Practice Address - Phone:202-460-6219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-27
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
385HR2065X, 385HR2060X
MD251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No385HR2065XRespite Care FacilityRespite CareRespite Care, Physical Disabilities, Child
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD9DMedicaid