Provider Demographics
NPI:1942738133
Name:IYEBOTE, LINDA OWUSUAA (LICSW)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:OWUSUAA
Last Name:IYEBOTE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:
Other - Last Name:NSIAH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LGSW
Mailing Address - Street 1:6019 ARCHSTONE WAY APT 401
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22310-5526
Mailing Address - Country:US
Mailing Address - Phone:703-300-6473
Mailing Address - Fax:
Practice Address - Street 1:6019 ARCHSTONE WAY APT 401
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22310-5526
Practice Address - Country:US
Practice Address - Phone:703-300-6473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-01
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLG50081492104100000X
MD21638104100000X
DCLC500820151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker