Healthcare Provider Details

I. General information

NPI: 1326102799
Provider Name (Legal Business Name): PRINCE WILIAM FAMILY COUNSELING, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9625 SURVEYOR CT SUITE 200
MANASSAS VA
20110-4422
US

IV. Provider business mailing address

9625 SURVEYOR CT SUITE 200
MANASSAS VA
20110-4422
US

V. Phone/Fax

Practice location:
  • Phone: 703-330-9933
  • Fax: 703-368-8454
Mailing address:
  • Phone: 703-330-9933
  • Fax: 703-368-8454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0904002397
License Number StateVA

VIII. Authorized Official

Name: DR. HENRY KOCH
Title or Position: DIRECTOR
Credential: PSYCHOLOGIST
Phone: 703-330-9933