Provider Demographics
NPI:1528364130
Name:BOOSALIS PSYCHOLOGICAL SERVICES
Entity Type:Organization
Organization Name:BOOSALIS PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ELENI
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:BOOSALIS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:703-408-6142
Mailing Address - Street 1:8401 DORSEY CIR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-8303
Mailing Address - Country:US
Mailing Address - Phone:703-408-6142
Mailing Address - Fax:703-656-4868
Practice Address - Street 1:8401 DORSEY CIR
Practice Address - Street 2:SUITE 102
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-8303
Practice Address - Country:US
Practice Address - Phone:703-408-6142
Practice Address - Fax:703-656-4868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-28
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810003954103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty