Provider Demographics
NPI:1447421920
Name:INTEGRATED CLINICAL CONCEPTS
Entity Type:Organization
Organization Name:INTEGRATED CLINICAL CONCEPTS
Other - Org Name:ASSOCIATED CLINICAL SERVICES OF HERNDON
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:L
Authorized Official - Last Name:WALD
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:703-481-6001
Mailing Address - Street 1:481 CARLISLE DRIVE
Mailing Address - Street 2:SUITE 112
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170
Mailing Address - Country:US
Mailing Address - Phone:703-481-6001
Mailing Address - Fax:703-481-5664
Practice Address - Street 1:481 CARLISLE DRIVE
Practice Address - Street 2:SUITE 112
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170
Practice Address - Country:US
Practice Address - Phone:703-481-6001
Practice Address - Fax:703-481-5664
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-12
Last Update Date:2009-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA101Y00000X, 103TC0700X
101YP2500X, 103TC0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty