Healthcare Provider Details

I. General information

NPI: 1447838651
Provider Name (Legal Business Name): SUSAN T FABIAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SUSAN FABIAN HOLLER LCSW

II. Dates (important events)

Enumeration Date: 03/30/2021
Last Update Date: 04/23/2021
Certification Date: 04/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8221 WILLOW OAKS CORPORATE DR # 4-420
FAIRFAX VA
22031-4512
US

IV. Provider business mailing address

PO BOX 37174
BALTIMORE MD
21297-3174
US

V. Phone/Fax

Practice location:
  • Phone: 703-289-7560
  • Fax: 703-204-9001
Mailing address:
  • Phone: 571-423-5699
  • Fax: 571-423-5698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904006298
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: