Healthcare Provider Details

I. General information

NPI: 1356977458
Provider Name (Legal Business Name): LAUREN RIVERS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2020
Last Update Date: 03/20/2020
Certification Date: 03/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10650 MAIN ST
FAIRFAX VA
22030-3814
US

IV. Provider business mailing address

1023 N ROYAL ST UNIT 304
ALEXANDRIA VA
22314-1597
US

V. Phone/Fax

Practice location:
  • Phone: 571-418-1714
  • Fax:
Mailing address:
  • Phone: 251-228-0745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: