Provider Demographics
NPI:1942400189
Name:SMILE FOR LIFE BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:SMILE FOR LIFE BEHAVIORAL HEALTH
Other - Org Name:SMILE FOR LIFE BEHAVIORAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PSYCHIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SWARNALATHA
Authorized Official - Middle Name:
Authorized Official - Last Name:PRASANNA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-492-0500
Mailing Address - Street 1:1455 OLD BRIDGE RD STE 206
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-2727
Mailing Address - Country:US
Mailing Address - Phone:703-492-0500
Mailing Address - Fax:703-497-0806
Practice Address - Street 1:1455 OLD BRIDGE RD
Practice Address - Street 2:SUITE 206
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-2727
Practice Address - Country:US
Practice Address - Phone:703-492-0500
Practice Address - Fax:703-497-0806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-24
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101232216305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC09294Medicare PIN
VAI22864Medicare UPIN