Provider Demographics
NPI:1255090437
Name:MOGES, KASSAYE TEKOLA
Entity type:Individual
Prefix:
First Name:KASSAYE
Middle Name:TEKOLA
Last Name:MOGES
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 1:2000 DENNIS AVE STE 22
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20902-4136
Mailing Address - Country:US
Mailing Address - Phone:703-731-0094
Mailing Address - Fax:240-777-1039
Practice Address - Street 1:2000 DENNIS AVE STE 22
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20902-4136
Practice Address - Country:US
Practice Address - Phone:703-731-0094
Practice Address - Fax:240-777-1039
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-15
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD200341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical