Healthcare Provider Details

I. General information

NPI: 1346623576
Provider Name (Legal Business Name): IRENA MORIN FEDOROVSKY PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2015
Last Update Date: 07/07/2015
Certification Date:
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: 703-573-3573
  • Fax: 703-573-3574
Mailing address:
  • Phone: 703-573-3573
  • Fax: 703-573-3574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810005119
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number05524
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY1001033
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: