Provider Demographics
NPI:1922858794
Name:EVIDENCE BASED TREATMENT COLLABORATIVE
Entity Type:Organization
Organization Name:EVIDENCE BASED TREATMENT COLLABORATIVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JOANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARINO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:571-477-1611
Mailing Address - Street 1:4000 LEGATO RD FL 11
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2892
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4000 LEGATO RD FL 11
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-2892
Practice Address - Country:US
Practice Address - Phone:571-206-1747
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)