Provider Demographics
NPI:1679064232
Name:CONDE, FANTA (DMFT, LMFT)
Entity type:Individual
Prefix:DR
First Name:FANTA
Middle Name:
Last Name:CONDE
Suffix:
Gender:F
Credentials:DMFT, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18303 BUBBLING SPRING TERRACE
Mailing Address - Street 2:
Mailing Address - City:BOYDS
Mailing Address - State:MD
Mailing Address - Zip Code:20841
Mailing Address - Country:US
Mailing Address - Phone:301-213-0750
Mailing Address - Fax:
Practice Address - Street 1:105 ORONOCO ST STE 305
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-2089
Practice Address - Country:US
Practice Address - Phone:301-213-0750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-19
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3482106H00000X
FLMT3482106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist