Healthcare Provider Details

I. General information

NPI: 1770178816
Provider Name (Legal Business Name): 360 INNOVATIVE THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2021
Last Update Date: 03/01/2021
Certification Date: 02/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10304 EATON PL STE 100
FAIRFAX VA
22030-2238
US

IV. Provider business mailing address

10304 EATON PL STE 100
FAIRFAX VA
22030-2238
US

V. Phone/Fax

Practice location:
  • Phone: 571-575-3767
  • Fax: 877-525-1222
Mailing address:
  • Phone: 571-575-3767
  • Fax: 877-525-1222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name: BEVERLY MCNAIRY
Title or Position: CEO
Credential: ED.M.
Phone: 571-575-3767