MEDICARE: ALEXANDRIA THERAPY, 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	103TC0700X	Clinical Psychologist
2	103T00000X	Psychologist

General Provider Information

NPI Number	:	1831722313
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALEXANDRIA THERAPY, LLC

Provider Business Mailing Address
First Line	:	2210 MOUNT VERNON AVE # ARE204
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22301-1394
Country	:	US
Telephone Number	:	703-286-0406
Fax Number	:

Provider Business Practice Location Address
First Line	:	2210 MOUNT VERNON AVE STE 204
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22301-1361
Country	:	US
Telephone Number	:	703-286-0406
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ANGEL DANIELS
Credential	:	PHD
Telephone Number	:	703-286-0406

Provider Enumeration Date	:	02/12/2020
Last Update Date	:	02/12/2020

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