Provider Demographics
NPI:1417469974
Name:LIFELINE PSYCHOTHERAPY SERVICES
Entity Type:Organization
Organization Name:LIFELINE PSYCHOTHERAPY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HOANG OANH
Authorized Official - Middle Name:
Authorized Official - Last Name:RODGERS
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT, LPC
Authorized Official - Phone:703-409-6258
Mailing Address - Street 1:12646 HERON RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-6638
Mailing Address - Country:US
Mailing Address - Phone:703-409-6258
Mailing Address - Fax:
Practice Address - Street 1:11350 RANDOM HILLS RD STE 800
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-6044
Practice Address - Country:US
Practice Address - Phone:703-409-6258
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-24
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0710000893101YA0400X
VA0701002418101YP2500X
VA0717000800106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty