Provider Demographics
NPI:1124452123
Name:DEFOE, DAVID IMAMU
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:IMAMU
Last Name:DEFOE
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 1:14502 GREENVIEW DR STE 202
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20708-3287
Mailing Address - Country:US
Mailing Address - Phone:240-581-1500
Mailing Address - Fax:240-513-4122
Practice Address - Street 1:14502 GREENVIEW DR STE 202
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20708-3287
Practice Address - Country:US
Practice Address - Phone:301-821-0049
Practice Address - Fax:240-513-4122
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-26
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC6147101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD873928Medicaid