Healthcare Provider Details

I. General information

NPI: 1861410821
Provider Name (Legal Business Name): BRIAN HENRY MARVIN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 05/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14150 PARKEAST CIR STE 200 SUITE 200
CHANTILLY VA
20151-4212
US

IV. Provider business mailing address

3525 AUSTIN AVE
ALEXANDRIA VA
22310-3103
US

V. Phone/Fax

Practice location:
  • Phone: 703-968-4000
  • Fax: 703-263-1724
Mailing address:
  • Phone: 703-960-5798
  • Fax: 703-263-1724

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904003231
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: