Provider Demographics
NPI:1588926539
Name:TEVIBENISSAN, GUY R
Entity type:Individual
Prefix:
First Name:GUY
Middle Name:R
Last Name:TEVIBENISSAN
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 1:7713 CARROLL AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:TAKOMA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20912-7773
Mailing Address - Country:US
Mailing Address - Phone:202-705-3589
Mailing Address - Fax:
Practice Address - Street 1:7713 CARROLL AVE APT 3
Practice Address - Street 2:
Practice Address - City:TAKOMA PARK
Practice Address - State:MD
Practice Address - Zip Code:20912-7773
Practice Address - Country:US
Practice Address - Phone:202-705-3589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-14
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide