Provider Demographics
NPI:1811787872
Name:LEGESSE, KANAAN
Entity type:Individual
Prefix:
First Name:KANAAN
Middle Name:
Last Name:LEGESSE
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:CANAAN
Other - Middle Name:
Other - Last Name:TESFAYE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:7420 FULLERTON RD STE 110
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22153-2836
Mailing Address - Country:US
Mailing Address - Phone:240-342-2666
Mailing Address - Fax:
Practice Address - Street 1:7420 FULLERTON RD STE 110
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22153-2836
Practice Address - Country:US
Practice Address - Phone:240-342-2666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-12
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician