Provider Demographics
NPI:1639687312
Name:PEARL VITALITY COUNSELING
Entity Type:Organization
Organization Name:PEARL VITALITY COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST/ LCSW
Authorized Official - Prefix:
Authorized Official - First Name:TALIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRYAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:757-358-1771
Mailing Address - Street 1:650 POTOMAC AVE APT 410
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22301-3072
Mailing Address - Country:US
Mailing Address - Phone:757-358-1771
Mailing Address - Fax:
Practice Address - Street 1:4809 EISENHOWER AVE STE B
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-4832
Practice Address - Country:US
Practice Address - Phone:757-358-1771
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-17
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904008852251S00000X, 261QM0855X
261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health