Provider Demographics
NPI:1033812045
Name:COLLABORATIVE SUPPORT PSYCHOLOGICAL SERVICES PLLC
Entity Type:Organization
Organization Name:COLLABORATIVE SUPPORT PSYCHOLOGICAL SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:ANETA
Authorized Official - Middle Name:
Authorized Official - Last Name:KERN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:703-915-3025
Mailing Address - Street 1:1224 BISHOPSGATE WAY
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20194-1414
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1224 BISHOPSGATE WAY
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20194-1414
Practice Address - Country:US
Practice Address - Phone:703-915-3025
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty