Provider Demographics
NPI:1215546353
Name:NUR, FARDOWSA HUSSEIN (LBA)
Entity Type:Individual
Prefix:
First Name:FARDOWSA
Middle Name:HUSSEIN
Last Name:NUR
Suffix:
Gender:F
Credentials:LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3321 WILLIAM JOHNSTON LN APT 22
Mailing Address - Street 2:
Mailing Address - City:DUMFRIES
Mailing Address - State:VA
Mailing Address - Zip Code:22026-2156
Mailing Address - Country:US
Mailing Address - Phone:571-552-7024
Mailing Address - Fax:571-552-7024
Practice Address - Street 1:297 HERNDON PKWY STE 301
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-4469
Practice Address - Country:US
Practice Address - Phone:571-241-8557
Practice Address - Fax:571-303-1835
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-24
Last Update Date:2023-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
VA0133002508103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician