Provider Demographics
NPI:1174136691
Name:MBAH, TITANJI VICTORY
Entity type:Individual
Prefix:
First Name:TITANJI
Middle Name:VICTORY
Last Name:MBAH
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 1:6735 NEW HAMPSHIRE AVE APT T3
Mailing Address - Street 2:
Mailing Address - City:TAKOMA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20912-4811
Mailing Address - Country:US
Mailing Address - Phone:240-860-4885
Mailing Address - Fax:
Practice Address - Street 1:6475 NEW HAMPSHIRE AVE STE 315
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20783-3282
Practice Address - Country:US
Practice Address - Phone:240-315-3101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA15350251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health