Healthcare Provider Details

I. General information

NPI: 1447421920
Provider Name (Legal Business Name): INTEGRATED CLINICAL CONCEPTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2008
Last Update Date: 10/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

481 CARLISLE DRIVE SUITE 112
HERNDON VA
20170
US

IV. Provider business mailing address

481 CARLISLE DRIVE SUITE 112
HERNDON VA
20170
US

V. Phone/Fax

Practice location:
  • Phone: 703-481-6001
  • Fax: 703-481-5664
Mailing address:
  • Phone: 703-481-6001
  • Fax: 703-481-5664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateVA
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: JUDITH L WALD
Title or Position: OWNER
Credential: PSYD
Phone: 703-481-6001