Provider Demographics
NPI:1801588744
Name:TRIUMPHANT LEADERS OF DMV YOUTH PROGRAM
Entity type:Organization
Organization Name:TRIUMPHANT LEADERS OF DMV YOUTH PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CANNADAY
Authorized Official - Suffix:
Authorized Official - Credentials:ASSOCIATES DEGREE
Authorized Official - Phone:202-683-0575
Mailing Address - Street 1:PO BOX 30124
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20030-0124
Mailing Address - Country:US
Mailing Address - Phone:202-683-0575
Mailing Address - Fax:
Practice Address - Street 1:3430 21ST ST SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-6109
Practice Address - Country:US
Practice Address - Phone:202-683-0575
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health