Healthcare Provider Details

I. General information

NPI: 1194804914
Provider Name (Legal Business Name): BARRY B EKDOM PHD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 06/04/2024
Certification Date: 06/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3040 WILLIAMS DR SUITE 402
FAIRFAX VA
22031-4618
US

IV. Provider business mailing address

3040 WILLIAMS DR SUITE 402
FAIRFAX VA
22031-4618
US

V. Phone/Fax

Practice location:
  • Phone: 703-573-3575
  • Fax: 703-573-3574
Mailing address:
  • Phone: 703-573-3575
  • Fax: 703-573-3574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number081001775
License Number StateVA

VIII. Authorized Official

Name: DR. NICOLE HASHEMIAN
Title or Position: OWNER
Credential: PSYD
Phone: 703-573-3573