Healthcare Provider Details

I. General information

NPI: 1306673611
Provider Name (Legal Business Name): NOVA THERAPY LOUNGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2024
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43546 MINK MEADOWS ST
CHANTILLY VA
20152-3611
US

IV. Provider business mailing address

43546 MINK MEADOWS ST
CHANTILLY VA
20152-3611
US

V. Phone/Fax

Practice location:
  • Phone: 571-409-1783
  • Fax:
Mailing address:
  • Phone: 571-409-1783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MARJOLIJN NARSIS HIEMSTRA
Title or Position: LICENSED PROFESSIONAL COUNSELOR
Credential: LPC, NLP
Phone: 571-409-1783