Provider Demographics
NPI:1043613474
Name:PROSPERITY EATING DISORDER AND WELLNESS
Entity Type:Organization
Organization Name:PROSPERITY EATING DISORDER AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:NELSON
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, CEDS
Authorized Official - Phone:703-466-5150
Mailing Address - Street 1:1031 STERLING RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-3865
Mailing Address - Country:US
Mailing Address - Phone:703-466-5150
Mailing Address - Fax:703-649-3557
Practice Address - Street 1:1031 STERLING RD
Practice Address - Street 2:SUITE 203
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-3865
Practice Address - Country:US
Practice Address - Phone:703-466-5150
Practice Address - Fax:703-649-3557
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROSPERITY EATING DISORDER AND WELLNESS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-09-30
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040054191041C0700X
261Q00000X, 261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Single Specialty