Provider Demographics
NPI:1780834911
Name:OCCOQUAN COUNSELING, LLC
Entity Type:Organization
Organization Name:OCCOQUAN COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:FACCIOLA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:703-203-7535
Mailing Address - Street 1:12866 HARBOR DR
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-2921
Mailing Address - Country:US
Mailing Address - Phone:703-203-7535
Mailing Address - Fax:703-563-9304
Practice Address - Street 1:12866 HARBOR DR
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-2921
Practice Address - Country:US
Practice Address - Phone:703-494-4164
Practice Address - Fax:703-563-9304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-24
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040050641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty