MEDICARE: MOUNT VERNON FAMILY THERAPY ASSOC. 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	101YM0800X	Mental Health Counselor	0701001872	VA

General Provider Information

NPI Number	:	1558661231
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOUNT VERNON FAMILY THERAPY ASSOC. LLC

Provider Business Mailing Address
First Line	:	1707 BELLE VIEW BLVD
Second Line	:	C-2
City	:	ALEXANDRIA
State	:	VA
Zip	:	22307-6727
Country	:	US
Telephone Number	:	703-768-6240
Fax Number	:	703-768-6264

Provider Business Practice Location Address
First Line	:	1707 BELLE VIEW BLVD
Second Line	:	C-2
City	:	ALEXANDRIA
State	:	VA
Zip	:	22307-6727
Country	:	US
Telephone Number	:	703-768-6240
Fax Number	:	703-768-6264

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. KRISTIN BRAMMER ROSENTHAL
Credential	:	MA, LPC
Telephone Number	:	703-768-6240

Provider Enumeration Date	:	10/27/2010
Last Update Date	:	10/27/2010

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