Healthcare Provider Details

I. General information

NPI: 1770239204
Provider Name (Legal Business Name): MY PSYCHIATRIST FALLS CHURCH, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2022
Last Update Date: 02/23/2022
Certification Date: 02/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6565 ARLINGTON BLVD
FALLS CHURCH VA
22042-3013
US

IV. Provider business mailing address

12359 SUNRISE VALLEY DR STE 320
RESTON VA
20191-3463
US

V. Phone/Fax

Practice location:
  • Phone: 703-596-4796
  • Fax:
Mailing address:
  • Phone: 35-964-7967
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. MADAN UPRETY
Title or Position: MEMBER
Credential: MD
Phone: 35-964-7967