Healthcare Provider Details

I. General information

NPI: 1619717790
Provider Name (Legal Business Name): MEDORA FRAZIER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2024
Last Update Date: 06/03/2024
Certification Date: 06/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N COLUMBUS ST STE 201
ALEXANDRIA VA
22314-2264
US

IV. Provider business mailing address

4345 WOODFIELD DR
POMFRET MD
20675-3220
US

V. Phone/Fax

Practice location:
  • Phone: 571-450-9145
  • Fax:
Mailing address:
  • Phone: 301-653-2314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number071012499
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: