Healthcare Provider Details

I. General information

NPI: 1124661368
Provider Name (Legal Business Name): DIANA MEREDITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2019
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10803 MAIN ST STE 700
FAIRFAX VA
22030-4728
US

IV. Provider business mailing address

10803 MAIN ST STE 700
FAIRFAX VA
22030-4728
US

V. Phone/Fax

Practice location:
  • Phone: 888-574-6007
  • Fax:
Mailing address:
  • Phone: 888-574-6007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number0133005349
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: