Provider Demographics
NPI:1831569896
Name:NORTHERN VIRGINIA OLDER ADULT COUNSELING
Entity type:Organization
Organization Name:NORTHERN VIRGINIA OLDER ADULT COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER/OPERATIONS OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-424-0410
Mailing Address - Street 1:4700 BANTING CT
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22032-2451
Mailing Address - Country:US
Mailing Address - Phone:703-424-0410
Mailing Address - Fax:
Practice Address - Street 1:4700 BANTING CT
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22032-2451
Practice Address - Country:US
Practice Address - Phone:703-424-0410
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-03
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904006279251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health