Healthcare Provider Details

I. General information

NPI: 1386662971
Provider Name (Legal Business Name): ADULT AND GERIATRIC PSYCHIATRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 11/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19415 DEERFIELD AVE STE 310
LANSDOWNE VA
20176-8452
US

IV. Provider business mailing address

PO BOX 825
ASHBURN VA
20146-0825
US

V. Phone/Fax

Practice location:
  • Phone: 703-858-0076
  • Fax: 703-726-6394
Mailing address:
  • Phone: 703-858-0076
  • Fax: 703-726-6394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0101232595
License Number StateVA

VIII. Authorized Official

Name: TARA MANGAT
Title or Position: PRESIDENT
Credential: MD
Phone: 703-858-0076