Healthcare Provider Details

I. General information

NPI: 1326522871
Provider Name (Legal Business Name): ELLEN BRIGHAM ATR-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2018
Last Update Date: 09/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11230 WAPLES MILL RD STE 100
FAIRFAX VA
22030-6087
US

IV. Provider business mailing address

14464 GLENCREST CIR
CENTREVILLE VA
20120-4131
US

V. Phone/Fax

Practice location:
  • Phone: 703-309-4363
  • Fax:
Mailing address:
  • Phone: 703-309-4363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number18-076
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: