Healthcare Provider Details

I. General information

NPI: 1891689386
Provider Name (Legal Business Name): MARY ABRAHAM PSYD
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2025
Last Update Date: 11/04/2025
Certification Date: 11/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9677 MAIN ST STE A-B
FAIRFAX VA
22031-3763
US

IV. Provider business mailing address

8401 MAYLAND DR STE A
RICHMOND VA
23294-4648
US

V. Phone/Fax

Practice location:
  • Phone: 301-767-1733
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810009162
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: