Provider Demographics
NPI:1902584782
Name:WANDJI, BLECK CHE ROY
Entity Type:Individual
Prefix:
First Name:BLECK CHE
Middle Name:ROY
Last Name:WANDJI
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 1:10807 POOKEY WAY
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-6041
Mailing Address - Country:US
Mailing Address - Phone:240-872-8873
Mailing Address - Fax:
Practice Address - Street 1:10807 POOKEY WAY
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20774-6041
Practice Address - Country:US
Practice Address - Phone:240-872-8873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-10
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator