Healthcare Provider Details

I. General information

NPI: 1053347476
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: 06/25/2006
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: 703-323-4000
  • Fax: 703-323-4252
Mailing address:
  • Phone: 703-323-4000
  • Fax: 703-323-4252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: DR. MARK S DIORIO
Title or Position: FACILITY DIRECTOR
Credential: PH.D., MPH
Phone: 703-323-4002