Healthcare Provider Details

I. General information

NPI: 1811891443
Provider Name (Legal Business Name): IDEAN JOSEPHINE FORTUNE II LSATP, MAC, CSAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4213 WALNEY RD
CHANTILLY VA
20151-2923
US

IV. Provider business mailing address

4213 WALNEY RD
CHANTILLY VA
20151-2923
US

V. Phone/Fax

Practice location:
  • Phone: 703-502-7060
  • Fax: 703-502-7006
Mailing address:
  • Phone: 703-502-7020
  • Fax: 703-502-7006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0718000814
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: