Healthcare Provider Details

I. General information

NPI: 1972039634
Provider Name (Legal Business Name): ELEONORA SADIKOVA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2017
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9707 KEY WEST AVE STE 100
ROCKVILLE MD
20850-3992
US

IV. Provider business mailing address

4132 E JACK JOUETT RD
LOUISA VA
23093-3140
US

V. Phone/Fax

Practice location:
  • Phone: 240-750-6467
  • Fax:
Mailing address:
  • Phone: 703-405-9723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810008678
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: