Provider Demographics
NPI:1992474761
Name:EL-TAYUDDIN, ISMAEL MOHAMMED
Entity type:Individual
Prefix:MR
First Name:ISMAEL
Middle Name:MOHAMMED
Last Name:EL-TAYUDDIN
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 1:21576 IREDELL TER
Mailing Address - Street 2:
Mailing Address - City:BROADLANDS
Mailing Address - State:VA
Mailing Address - Zip Code:20148-5033
Mailing Address - Country:US
Mailing Address - Phone:510-738-7709
Mailing Address - Fax:844-333-0432
Practice Address - Street 1:21576 IREDELL TER
Practice Address - Street 2:
Practice Address - City:BROADLANDS
Practice Address - State:VA
Practice Address - Zip Code:20148-5033
Practice Address - Country:US
Practice Address - Phone:510-738-7709
Practice Address - Fax:844-333-0432
Is Sole Proprietor?:No
Enumeration Date:2021-09-07
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133002040103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst