Healthcare Provider Details

I. General information

NPI: 1164912820
Provider Name (Legal Business Name): LANA ADIL MAHGOUB PHD, LP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2018
Last Update Date: 10/21/2025
Certification Date: 10/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21525 RIDGETOP CIR STE 110
DULLES VA
20166-6510
US

IV. Provider business mailing address

21525 RIDGETOP CIR STE 110
DULLES VA
20166-6510
US

V. Phone/Fax

Practice location:
  • Phone: 703-662-1719
  • Fax:
Mailing address:
  • Phone: 703-662-1719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number11460
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810006314
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: