Healthcare Provider Details

I. General information

NPI: 1184907537
Provider Name (Legal Business Name): MONICA HAYWARD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2011
Last Update Date: 09/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5105Q BACKLICK RD
ANNANDALE VA
22003-6005
US

IV. Provider business mailing address

4707 KENNY CT
WOODBRIDGE VA
22193-4805
US

V. Phone/Fax

Practice location:
  • Phone: 703-232-0874
  • Fax: 703-590-3081
Mailing address:
  • Phone: 703-232-0874
  • Fax: 703-590-3081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number0904007729
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number0904007729
License Number StateVA

VIII. Authorized Official

Name: MRS. MONICA N HAYWARD
Title or Position: PSYCHOTHERPIST
Credential: L.C.S.W
Phone: 703-232-0874