Provider Demographics
NPI:1811171309
Name:COMMONWEALTH OF VIRGINIA DEPT OF MENTAL HEALTH AND NORTHERN VIRGINIA T
Entity type:Organization
Organization Name:COMMONWEALTH OF VIRGINIA DEPT OF MENTAL HEALTH AND NORTHERN VIRGINIA T
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHAQUWANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-323-4093
Mailing Address - Street 1:9901 BRADDOCK RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22032-1904
Mailing Address - Country:US
Mailing Address - Phone:703-323-4093
Mailing Address - Fax:
Practice Address - Street 1:9901 BRADDOCK RD
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22032-1904
Practice Address - Country:US
Practice Address - Phone:703-323-4093
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-20
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101040712208000000X
VA01010469232084N0400X
VA01010345452084P0005X
VA0101233274207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No2084P0005XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurodevelopmental DisabilitiesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAE93555Medicare UPIN
VAI34189Medicare UPIN
VAC62714Medicare UPIN
VAE38521Medicare UPIN