Provider Demographics
NPI:1760781512
Name:FARDIS, MAKON (PHD)
Entity Type:Individual
Prefix:DR
First Name:MAKON
Middle Name:
Last Name:FARDIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4743 BRADLEY BLVD
Mailing Address - Street 2:# 302
Mailing Address - City:CHEVY CHASE
Mailing Address - State:MD
Mailing Address - Zip Code:20815-6303
Mailing Address - Country:US
Mailing Address - Phone:406-531-5664
Mailing Address - Fax:
Practice Address - Street 1:2029 P ST NW
Practice Address - Street 2:SUITE 302
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20036-5948
Practice Address - Country:US
Practice Address - Phone:202-906-9614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-18
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPSY 1000573103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical