Healthcare Provider Details

I. General information

NPI: 1629328083
Provider Name (Legal Business Name): PRACTICAL THERAPEUTIC SOLUTIONS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2012
Last Update Date: 01/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10372 DEMOCRACY LN
FAIRFAX VA
22030-2522
US

IV. Provider business mailing address

10372 DEMOCRACY LN
FAIRFAX VA
22030-2522
US

V. Phone/Fax

Practice location:
  • Phone: 703-591-2551
  • Fax:
Mailing address:
  • Phone: 703-591-2551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number0904007483
License Number StateVA

VIII. Authorized Official

Name: JOHNNY S POWELL
Title or Position: MEMBER
Credential: LCSW
Phone: 703-801-5527