Provider Demographics
NPI:1114463346
Name:TAH, JUSTLINE
Entity type:Individual
Prefix:
First Name:JUSTLINE
Middle Name:
Last Name:TAH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 STREFORD WAY
Mailing Address - Street 2:UNIT 210
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20785-1234
Mailing Address - Country:US
Mailing Address - Phone:301-648-8594
Mailing Address - Fax:
Practice Address - Street 1:4017 MINNESOTA AVE NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-3541
Practice Address - Country:US
Practice Address - Phone:202-388-9202
Practice Address - Fax:202-388-4339
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-11
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC500018807163WP0809X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
No171M00000XOther Service ProvidersCase Manager/Care Coordinator