Healthcare Provider Details

I. General information

NPI: 1508641945
Provider Name (Legal Business Name): SALLY D FIFE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2023
Last Update Date: 08/28/2023
Certification Date: 08/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7716 RIDGECREST DR
ALEXANDRIA VA
22308-1051
US

IV. Provider business mailing address

1530 WILSON BLVD STE 650
ARLINGTON VA
22209-2455
US

V. Phone/Fax

Practice location:
  • Phone: 703-505-6009
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904015234
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: