Provider Demographics
NPI:1003498817
Name:KEBEDE, MIRAF SR
Entity type:Individual
Prefix:
First Name:MIRAF
Middle Name:
Last Name:KEBEDE
Suffix:SR
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 1:519 E INDIAN SPRING DR
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20901-4726
Mailing Address - Country:US
Mailing Address - Phone:240-476-6676
Mailing Address - Fax:
Practice Address - Street 1:519 E INDIAN SPRING DR
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20901-4726
Practice Address - Country:US
Practice Address - Phone:402-476-6676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-22
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC2000022351041C0700X
MD257111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD46905567200Medicaid