Provider Demographics
NPI:1487119707
Name:ELSIRAG, ABDELWAHAB ELTAYEB
Entity type:Individual
Prefix:
First Name:ABDELWAHAB
Middle Name:ELTAYEB
Last Name:ELSIRAG
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 1:12587 FAIR LAKES CIR STE 303
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-3822
Mailing Address - Country:US
Mailing Address - Phone:703-309-8733
Mailing Address - Fax:
Practice Address - Street 1:12587 FAIR LAKES CIR STE 303
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-3822
Practice Address - Country:US
Practice Address - Phone:703-309-8733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-01
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health