Healthcare Provider Details

I. General information

NPI: 1497647424
Provider Name (Legal Business Name): BRIAN YEAGLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2025
Last Update Date: 07/15/2025
Certification Date: 07/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4155 CHAIN BRIDGE RD
FAIRFAX VA
22030-4102
US

IV. Provider business mailing address

7410 HEATHERFIELD LN
ALEXANDRIA VA
22315-5287
US

V. Phone/Fax

Practice location:
  • Phone: 703-258-9331
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0704016411
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: