Provider Demographics
NPI:1548068745
Name:MBAH, DIVINE
Entity type:Individual
Prefix:
First Name:DIVINE
Middle Name:
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 1:6827 RIVERDALE RD RIVERDALE
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20737-1846
Mailing Address - Country:US
Mailing Address - Phone:240-861-4783
Mailing Address - Fax:
Practice Address - Street 1:2600 BRYAN PL SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-4417
Practice Address - Country:US
Practice Address - Phone:240-861-4783
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-04
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator