Provider Demographics
NPI:1770016461
Name:THREE LEAVES PSYCHOLOGICAL SERVICES LLC
Entity Type:Organization
Organization Name:THREE LEAVES PSYCHOLOGICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:
Authorized Official - Last Name:DREILING
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:213-344-9008
Mailing Address - Street 1:25996 TALAMORE DR
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20152-1758
Mailing Address - Country:US
Mailing Address - Phone:213-344-9008
Mailing Address - Fax:
Practice Address - Street 1:11307 SUNSET HILLS RD
Practice Address - Street 2:B-4
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5278
Practice Address - Country:US
Practice Address - Phone:213-344-9008
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-10
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810005362103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty