Healthcare Provider Details

I. General information

NPI: 1770003311
Provider Name (Legal Business Name): INCEPTUS PSYCHOLOGICAL & CONSULTING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 PENDLETON ST STE 202
ALEXANDRIA VA
22314-1820
US

IV. Provider business mailing address

709 PENDLETON ST STE 202
ALEXANDRIA VA
22314-1820
US

V. Phone/Fax

Practice location:
  • Phone: 703-786-5486
  • Fax: 703-842-8746
Mailing address:
  • Phone: 703-786-5486
  • Fax: 703-842-8746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0701007049
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810004954
License Number StateVA

VIII. Authorized Official

Name: DR. TAMEKA MALLARD TUCKER
Title or Position: LICENSED CLINICAL PSYCHOLOGIST
Credential: PH.D.
Phone: 703-786-5486