Provider Demographics
NPI:1811556434
Name:NORTHERN VIRGINIA PSYCHOLOGY PROFESSIONALS, LLC
Entity Type:Organization
Organization Name:NORTHERN VIRGINIA PSYCHOLOGY PROFESSIONALS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:703-662-3637
Mailing Address - Street 1:1768 BUSINESS CENTER DR STE 360
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-5358
Mailing Address - Country:US
Mailing Address - Phone:703-662-3637
Mailing Address - Fax:571-926-8404
Practice Address - Street 1:1768 BUSINESS CENTER DR STE 360
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5358
Practice Address - Country:US
Practice Address - Phone:703-662-3637
Practice Address - Fax:703-437-6872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-07
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)