Healthcare Provider Details

I. General information

NPI: 1639687312
Provider Name (Legal Business Name): PEARL VITALITY COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2018
Last Update Date: 01/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4809 EISENHOWER AVE STE B
ALEXANDRIA VA
22304-4832
US

IV. Provider business mailing address

650 POTOMAC AVE APT 410
ALEXANDRIA VA
22301-3072
US

V. Phone/Fax

Practice location:
  • Phone: 757-358-1771
  • Fax:
Mailing address:
  • Phone: 757-358-1771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number0904008852
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number0904008852
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TALIA BRYAN
Title or Position: THERAPIST/ LCSW
Credential: LCSW
Phone: 757-358-1771