MEDICARE: ENGLEFIELDPSYCHOTHERAPY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0855X	Adolescent and Children Mental Health Clinic/Center
2	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1073258273
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ENGLEFIELDPSYCHOTHERAPY, LLC

Provider Business Mailing Address
First Line	:	1017 DALEBROOK DR
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22308-2615
Country	:	US
Telephone Number	:	703-307-7855
Fax Number	:

Provider Business Practice Location Address
First Line	:	215 N PAYNE ST
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22314-2444
Country	:	US
Telephone Number	:	703-307-7855
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MATTHEW ENGLEFIELD
Credential	:
Telephone Number	:	703-307-7855

Provider Enumeration Date	:	05/02/2022
Last Update Date	:	05/02/2022

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