Provider Demographics
NPI:1417107772
Name:FAIRFAX METHADONE TREATMENT CENTER
Entity Type:Organization
Organization Name:FAIRFAX METHADONE TREATMENT CENTER
Other - Org Name:FMTC
Other - Org Type:Other Name
Authorized Official - Title/Position:ASSISTANT PROGRAM DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCLELLAND
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC, LCAS, CCS
Authorized Official - Phone:703-333-3113
Mailing Address - Street 1:7008 LITTLE RIVER TPKE STE G
Mailing Address - Street 2:
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003-3234
Mailing Address - Country:US
Mailing Address - Phone:703-333-3113
Mailing Address - Fax:703-333-3116
Practice Address - Street 1:7008 LITTLE RIVER TPKE STE G
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-3234
Practice Address - Country:US
Practice Address - Phone:703-333-3113
Practice Address - Fax:703-333-3116
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SELLATI & CO., INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-23
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA089251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health