Healthcare Provider Details

I. General information

NPI: 1053240713
Provider Name (Legal Business Name): FAIRFAX COUNTY GROUP HOMES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 RANDOLPH ST
FALLS CHURCH VA
22046-2811
US

IV. Provider business mailing address

804 RANDOLPH ST
FALLS CHURCH VA
22046-2811
US

V. Phone/Fax

Practice location:
  • Phone: 703-209-5160
  • Fax: 571-441-6247
Mailing address:
  • Phone: 703-209-5160
  • Fax: 571-441-6247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VIII. Authorized Official

Name: DEEPA GILL
Title or Position: OWNER
Credential:
Phone: 703-209-5160