Healthcare Provider Details

I. General information

NPI: 1346764669
Provider Name (Legal Business Name): GREATER WASHINGTON COUNSELING AND MENTAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 UNIVERSITY DR STE 320
FAIRFAX VA
22030-2513
US

IV. Provider business mailing address

9198 SILVERLINE DR
FAIRFAX STATION VA
22039-3109
US

V. Phone/Fax

Practice location:
  • Phone: 301-213-6637
  • Fax: 703-563-9277
Mailing address:
  • Phone: 301-213-6637
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number701006194
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number701006194
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number701006194
License Number StateVA

VIII. Authorized Official

Name: MR. MICHAEL C LIEBERMAN
Title or Position: OWNER
Credential: LPC
Phone: 301-213-6637