Provider Demographics
NPI:1124673777
Name:TACHI, BELTTA GANGWAB
Entity type:Individual
Prefix:MRS
First Name:BELTTA
Middle Name:GANGWAB
Last Name:TACHI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2320 HOLLY SPRING DR
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20905-6403
Mailing Address - Country:US
Mailing Address - Phone:240-432-7050
Mailing Address - Fax:
Practice Address - Street 1:7501 GREENWAY CENTER DR STE 450
Practice Address - Street 2:
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-3544
Practice Address - Country:US
Practice Address - Phone:240-432-7050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-08
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR187251101YM0800X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty