Healthcare Provider Details

I. General information

NPI: 1124619267
Provider Name (Legal Business Name): KATHLEEN CLAGETT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2021
Last Update Date: 02/01/2021
Certification Date: 02/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8551 RIXLEW LN STE 100
MANASSAS VA
20109-4277
US

IV. Provider business mailing address

9000 LINTON LN
ALEXANDRIA VA
22308-2756
US

V. Phone/Fax

Practice location:
  • Phone: 540-212-6090
  • Fax:
Mailing address:
  • Phone: 703-517-4154
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0710103481
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: