Healthcare Provider Details

I. General information

NPI: 1376034629
Provider Name (Legal Business Name): PETRINA ERMINIA YEMANE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2018
Last Update Date: 05/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 S WASHINGTON ST STE 303
FALLS CHURCH VA
22046-2921
US

IV. Provider business mailing address

150 S WASHINGTON ST STE 303
FALLS CHURCH VA
22046-2921
US

V. Phone/Fax

Practice location:
  • Phone: 646-421-5594
  • Fax: 703-462-9121
Mailing address:
  • Phone: 646-421-5594
  • Fax: 703-462-9121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0701007657
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: