Healthcare Provider Details

I. General information

NPI: 1730523325
Provider Name (Legal Business Name): TERESA FLETCHER CTRS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2013
Last Update Date: 04/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13504 SPRINGHAVEN DR
FAIRFAX VA
22033-1204
US

IV. Provider business mailing address

13504 SPRINGHAVEN DR
FAIRFAX VA
22033-1204
US

V. Phone/Fax

Practice location:
  • Phone: 571-606-4004
  • Fax:
Mailing address:
  • Phone: 571-606-4004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number52370
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: