Healthcare Provider Details

I. General information

NPI: 1477323152
Provider Name (Legal Business Name): BROOKSIDE FAMILY THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2024
Last Update Date: 01/04/2024
Certification Date: 01/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9105A OWENS DR STE 102
MANASSAS PARK VA
20111-4852
US

IV. Provider business mailing address

7118 KNOTTY OAK LN
MANASSAS VA
20112-3235
US

V. Phone/Fax

Practice location:
  • Phone: 571-445-0265
  • Fax: 855-755-7769
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: KELLY AUSTIN
Title or Position: OWNER
Credential: LMFT
Phone: 571-331-9704