Provider Demographics
NPI:1972382745
Name:KOMLAN, KOUDZO
Entity type:Individual
Prefix:
First Name:KOUDZO
Middle Name:
Last Name:KOMLAN
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 1:1905 E ST SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20003-2593
Mailing Address - Country:US
Mailing Address - Phone:202-673-9319
Mailing Address - Fax:
Practice Address - Street 1:2311 RANDOLPH ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20018-3134
Practice Address - Country:US
Practice Address - Phone:202-929-9888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health