Provider Demographics
NPI:1568904373
Name:VINCENT, ELEANOR (EDD, LPC, CSAC)
Entity Type:Individual
Prefix:DR
First Name:ELEANOR
Middle Name:
Last Name:VINCENT
Suffix:
Gender:F
Credentials:EDD, LPC, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11350 RANDOM HILLS RD
Mailing Address - Street 2:8TH FLOOR
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-6044
Mailing Address - Country:US
Mailing Address - Phone:703-934-6006
Mailing Address - Fax:
Practice Address - Street 1:10560 MAIN ST
Practice Address - Street 2:SUITE 405
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-7182
Practice Address - Country:US
Practice Address - Phone:703-474-6427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-09
Last Update Date:2017-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0710102639101YA0400X
VA0701006683101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)