Provider Demographics
NPI:1639530629
Name:NURTURE CHILD AND FAMILY, PLLC
Entity Type:Organization
Organization Name:NURTURE CHILD AND FAMILY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:703-341-5995
Mailing Address - Street 1:1319 VINCENT PL
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-3615
Mailing Address - Country:US
Mailing Address - Phone:703-341-5995
Mailing Address - Fax:703-341-5995
Practice Address - Street 1:1319 VINCENT PL
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-3615
Practice Address - Country:US
Practice Address - Phone:703-341-5995
Practice Address - Fax:703-341-5995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-17
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA080003355103TC2200X
VA9040057961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty