Healthcare Provider Details

I. General information

NPI: 1639932577
Provider Name (Legal Business Name): POLARIS COUNSELING CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2024
Last Update Date: 02/02/2024
Certification Date: 02/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5274 LYNGATE CT
BURKE VA
22015-1688
US

IV. Provider business mailing address

10705 PAYNES CHURCH DR
FAIRFAX VA
22032-2940
US

V. Phone/Fax

Practice location:
  • Phone: 703-539-5914
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DAWN WEISS SMITH
Title or Position: OWNER
Credential: LCSW
Phone: 703-539-5914