Healthcare Provider Details

I. General information

NPI: 1578904702
Provider Name (Legal Business Name): ATLANTIC COUNSELING GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2013
Last Update Date: 06/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20925 PROFESSIONAL PLZ STE 230
ASHBURN VA
20147-3403
US

IV. Provider business mailing address

20925 PROFESSIONAL PLZ STE 230
ASHBURN VA
20147-3403
US

V. Phone/Fax

Practice location:
  • Phone: 703-665-0949
  • Fax: 703-665-7686
Mailing address:
  • Phone: 703-665-0949
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MR. MIKE VAZZANA
Title or Position: PARTNER
Credential: LPC
Phone: 703-665-0949