Provider Demographics
NPI:1184491078
Name:SANUSIAGBABIAKA, SAMSON
Entity type:Individual
Prefix:
First Name:SAMSON
Middle Name:
Last Name:SANUSIAGBABIAKA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15609 BIRCH RUN TER
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-3583
Mailing Address - Country:US
Mailing Address - Phone:347-299-3485
Mailing Address - Fax:
Practice Address - Street 1:4017 MINNESOTA AVE NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-3541
Practice Address - Country:US
Practice Address - Phone:202-388-9202
Practice Address - Fax:202-388-9209
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-11
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator