Provider Demographics
NPI:1891051413
Name:FOMBU, DIVINE (CSW)
Entity Type:Individual
Prefix:
First Name:DIVINE
Middle Name:
Last Name:FOMBU
Suffix:
Gender:M
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1706 HAMPSHIRE GREEN LN
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20903-2416
Mailing Address - Country:US
Mailing Address - Phone:202-545-0935
Mailing Address - Fax:
Practice Address - Street 1:13817 BRIARWOOD DR APT 1123
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20708-1345
Practice Address - Country:US
Practice Address - Phone:240-476-3253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-09
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator