Healthcare Provider Details

I. General information

NPI: 1295245066
Provider Name (Legal Business Name): DORIEN WADE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2017
Last Update Date: 10/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11240 WAPLES MILL RD STE 101
FAIRFAX VA
22030-6078
US

IV. Provider business mailing address

4200 HARDY RIDGE DR
WOODBRIDGE VA
22192-6642
US

V. Phone/Fax

Practice location:
  • Phone: 703-237-2219
  • Fax: 703-237-2729
Mailing address:
  • Phone: 703-595-6203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: