Healthcare Provider Details

I. General information

NPI: 1760978704
Provider Name (Legal Business Name): HEARTSWELL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2018
Last Update Date: 07/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 WILSON BLVD STE 702
ARLINGTON VA
22209-2505
US

IV. Provider business mailing address

1600 WILSON BLVD STE 702
ARLINGTON VA
22209-2505
US

V. Phone/Fax

Practice location:
  • Phone: 703-220-0951
  • Fax:
Mailing address:
  • Phone: 703-220-0951
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904007671
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number0904007671
License Number StateVA

VIII. Authorized Official

Name: LUANN C. OLIVER
Title or Position: OWNER
Credential: LCSW
Phone: 703-220-0951