Healthcare Provider Details

I. General information

NPI: 1386570521
Provider Name (Legal Business Name): NICOLE YASMINE ARDAIZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2751 PROSPERITY AVE STE 610
FAIRFAX VA
22031-4397
US

IV. Provider business mailing address

2751 PROSPERITY AVE STE 610
FAIRFAX VA
22031-4397
US

V. Phone/Fax

Practice location:
  • Phone: 703-560-2600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0704019134
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: