Healthcare Provider Details

I. General information

NPI: 1023874294
Provider Name (Legal Business Name): ELLIE ZADEH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2024
Last Update Date: 02/26/2024
Certification Date: 02/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3611 CHAIN BRIDGE RD
FAIRFAX VA
22030-3246
US

IV. Provider business mailing address

2600 SLEDDING HILL RD
OAKTON VA
22124-1540
US

V. Phone/Fax

Practice location:
  • Phone: 703-755-0107
  • Fax:
Mailing address:
  • Phone: 703-286-9296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0704015795
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: