Healthcare Provider Details

I. General information

NPI: 1922348713
Provider Name (Legal Business Name): MARY BALL BROWN PMHCNS, BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2013
Last Update Date: 02/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1761 OLD MEADOW RD
MC LEAN VA
22102-4315
US

IV. Provider business mailing address

1761 OLD MEADOW RD
MC LEAN VA
22102-4315
US

V. Phone/Fax

Practice location:
  • Phone: 703-531-6302
  • Fax: 703-448-3723
Mailing address:
  • Phone: 703-531-6302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number0001108010
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number0015000768
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: