Healthcare Provider Details

I. General information

NPI: 1689735573
Provider Name (Legal Business Name): ANTHONY PHILLIP MUCCIO LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 N SAINT ASAPH ST
ALEXANDRIA VA
22314-1912
US

IV. Provider business mailing address

13601 POST OAK CT
CHANTILLY VA
20151-2529
US

V. Phone/Fax

Practice location:
  • Phone: 703-838-4455
  • Fax:
Mailing address:
  • Phone: 703-378-1834
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701003875
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: