Healthcare Provider Details

I. General information

NPI: 1700402146
Provider Name (Legal Business Name): HEATHER L. BEBOUT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2020
Last Update Date: 06/22/2020
Certification Date: 06/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 FETTLER PARK DR
DUMFRIES VA
22025-2050
US

IV. Provider business mailing address

3700 FETTLER PARK DR
DUMFRIES VA
22025-2050
US

V. Phone/Fax

Practice location:
  • Phone: 703-441-7500
  • Fax:
Mailing address:
  • Phone: 703-441-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number138562
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: