Provider Demographics
NPI:1396286019
Name:FOUNTAIN OF LIFE LLC
Entity type:Organization
Organization Name:FOUNTAIN OF LIFE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:KLEWICKI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:571-277-4919
Mailing Address - Street 1:450 W BROAD ST STE 211
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22046-3318
Mailing Address - Country:US
Mailing Address - Phone:571-277-4919
Mailing Address - Fax:703-241-1122
Practice Address - Street 1:450 W BROAD ST STE 211
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22046-3318
Practice Address - Country:US
Practice Address - Phone:571-277-4919
Practice Address - Fax:703-241-1122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-14
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810002980103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty