Provider Demographics
NPI:1619351038
Name:ENDEPENDENCE CENTER OF NORTHERN VIRGINIA
Entity Type:Organization
Organization Name:ENDEPENDENCE CENTER OF NORTHERN VIRGINIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BREWSTER
Authorized Official - Middle Name:
Authorized Official - Last Name:THACKERAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-525-3268
Mailing Address - Street 1:2300 CLARENDON BLVD
Mailing Address - Street 2:305
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22201-3398
Mailing Address - Country:US
Mailing Address - Phone:703-525-3268
Mailing Address - Fax:703-525-3585
Practice Address - Street 1:2300 CLARENDON BLVD
Practice Address - Street 2:305
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22201-3398
Practice Address - Country:US
Practice Address - Phone:703-525-3268
Practice Address - Fax:703-525-3585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-15
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251X00000XAgenciesSupports Brokerage