Healthcare Provider Details

I. General information

NPI: 1376660233
Provider Name (Legal Business Name): LIVING FREE HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2007
Last Update Date: 08/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4306 EVERGREEN LN STE 204
ANNANDALE VA
22003-3217
US

IV. Provider business mailing address

4306 EVERGREEN LN STE 204
ANNANDALE VA
22003-3217
US

V. Phone/Fax

Practice location:
  • Phone: 703-750-1292
  • Fax: 703-642-0859
Mailing address:
  • Phone: 703-750-1292
  • Fax: 703-642-0859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number149
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number149
License Number StateVA

VIII. Authorized Official

Name: MS. MARIETTA WARDEN
Title or Position: PRESIDENT
Credential: R.N., C.C.S.,C.A.C
Phone: 703-750-1292