Healthcare Provider Details

I. General information

NPI: 1811171309
Provider Name (Legal Business Name): COMMONWEALTH OF VIRGINIA DEPT OF MENTAL HEALTH AND NORTHERN VIRGINIA T
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2007
Last Update Date: 06/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9901 BRADDOCK RD
FAIRFAX VA
22032-1904
US

IV. Provider business mailing address

9901 BRADDOCK RD
FAIRFAX VA
22032-1904
US

V. Phone/Fax

Practice location:
  • Phone: 703-323-4093
  • Fax:
Mailing address:
  • Phone: 703-323-4093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number0101233274
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101040712
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number0101046923
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code2084P0005X
TaxonomyNeurodevelopmental Disabilities Physician
License Number0101034545
License Number StateVA

VIII. Authorized Official

Name: SHAQUWANDA BAKER
Title or Position: OFFICE MANAGER
Credential:
Phone: 703-323-4093