Healthcare Provider Details

I. General information

NPI: 1841388865
Provider Name (Legal Business Name): INNOVATIVE CONSULTING INTERNATIONAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 06/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44025 PIPELINE PLZ SUITE 110
ASHBURN VA
20147-5881
US

IV. Provider business mailing address

44025 PIPELINE PLZ SUITE 110
ASHBURN VA
20147-5881
US

V. Phone/Fax

Practice location:
  • Phone: 703-636-2888
  • Fax: 703-991-9161
Mailing address:
  • Phone: 703-636-2888
  • Fax: 703-991-9161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number0701003624
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number09904004780
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0701003630
License Number StateVA

VIII. Authorized Official

Name: DR. CARY CRAIG MOORMAN
Title or Position: OWNER/PRESIDENT
Credential: PH.D.
Phone: 703-636-2888