Healthcare Provider Details

I. General information

NPI: 1194566117
Provider Name (Legal Business Name): MENTAL HEALTH THERAPY CENTER - NORTHERN VIRGINIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2024
Last Update Date: 06/04/2024
Certification Date: 06/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10721 MAIN ST STE 1300
FAIRFAX VA
22030-6902
US

IV. Provider business mailing address

10721 MAIN ST STE 1300
FAIRFAX VA
22030-6902
US

V. Phone/Fax

Practice location:
  • Phone: 703-536-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MIKE GINGRAS
Title or Position: DIVISION CFO
Credential:
Phone: 804-228-4901