Provider Demographics
NPI:1295252146
Name:FIDELIS THERAPY, LLC
Entity type:Organization
Organization Name:FIDELIS THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ELEANOR
Authorized Official - Middle Name:
Authorized Official - Last Name:VINCENT
Authorized Official - Suffix:
Authorized Official - Credentials:EDD, LPC, CSAC
Authorized Official - Phone:703-474-6427
Mailing Address - Street 1:11350 RANDOM HILLS RD FL 8
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-6044
Mailing Address - Country:US
Mailing Address - Phone:702-474-6427
Mailing Address - Fax:
Practice Address - Street 1:2555 CHAIN BRIDGE RD
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22181-5517
Practice Address - Country:US
Practice Address - Phone:703-474-6427
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-22
Last Update Date:2017-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701006683251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health