Healthcare Provider Details

I. General information

NPI: 1437223922
Provider Name (Legal Business Name): LIFE LINE ADDICTIONS FOUNDATION INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10374 DEMOCRACY LN STE A
FAIRFAX VA
22030-2557
US

IV. Provider business mailing address

4308 BEAVER DAM RD
JEFFERSONTON VA
22724-2001
US

V. Phone/Fax

Practice location:
  • Phone: 703-691-3029
  • Fax: 703-691-7410
Mailing address:
  • Phone: 540-347-9531
  • Fax: 703-691-7410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0718000188
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904006265
License Number StateVA

VIII. Authorized Official

Name: MR. GEORGE LYNDON SWANBERG
Title or Position: PRESIDENT
Credential: LCSW, LSATP, MAC
Phone: 703-691-3029