Provider Demographics
NPI:1679582308
Name:AGAPE MENTAL HEALTH AND CONSULTING
Entity Type:Organization
Organization Name:AGAPE MENTAL HEALTH AND CONSULTING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:FAY
Authorized Official - Middle Name:MARSHALL
Authorized Official - Last Name:PHILLIPS-LESANE
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:703-309-3031
Mailing Address - Street 1:PO BOX 4986
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22194-4986
Mailing Address - Country:US
Mailing Address - Phone:703-309-3031
Mailing Address - Fax:
Practice Address - Street 1:3095 P. S. BUSINESS CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192
Practice Address - Country:US
Practice Address - Phone:703-309-3031
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040033131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008939152Medicaid
VA301819OtherAMERIGROUP
VA110630OtherVALUE OPTIONS
VA187248OtherANTHEM BC/ BS
VAM283001OtherCAREFIRST