Healthcare Provider Details

I. General information

NPI: 1568914398
Provider Name (Legal Business Name): RACHEL WALLS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2016
Last Update Date: 01/24/2020
Certification Date: 01/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2740 PROSPERITY AVE
FAIRFAX VA
22031-4353
US

IV. Provider business mailing address

2740 PROSPERITY AVE STE 200
FAIRFAX VA
22031-4354
US

V. Phone/Fax

Practice location:
  • Phone: 703-321-2600
  • Fax: 703-321-2603
Mailing address:
  • Phone: 703-321-2600
  • Fax: 703-321-2603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904011041
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number73692
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: