Healthcare Provider Details

I. General information

NPI: 1356743280
Provider Name (Legal Business Name): THE MAIA INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2014
Last Update Date: 09/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 BALLENGER AVE STE 200
ALEXANDRIA VA
22314-6847
US

IV. Provider business mailing address

2050 BALLENGER AVE STE 200
ALEXANDRIA VA
22314-6847
US

V. Phone/Fax

Practice location:
  • Phone: 571-551-6070
  • Fax:
Mailing address:
  • Phone: 571-551-6070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License Number0101251413
License Number StateVA

VIII. Authorized Official

Name: CAROLINA A KLEIN
Title or Position: CHIEF MEDICAL OFFICER
Credential: MD
Phone: 202-596-9585