Provider Demographics
NPI:1760160147
Name:BONGORLIE, KORPO
Entity Type:Individual
Prefix:
First Name:KORPO
Middle Name:
Last Name:BONGORLIE
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 1:3 BETHESDA METRO CTR STE 700
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20814-6300
Mailing Address - Country:US
Mailing Address - Phone:240-292-8319
Mailing Address - Fax:855-568-2494
Practice Address - Street 1:134 DUVALL LANE
Practice Address - Street 2:APT 101
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877
Practice Address - Country:US
Practice Address - Phone:240-292-8319
Practice Address - Fax:855-568-2494
Is Sole Proprietor?:No
Enumeration Date:2023-07-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician