Healthcare Provider Details

I. General information

NPI: 1760342521
Provider Name (Legal Business Name): AUDREY D MEZA AMUNDARAY CSAC-S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2025
Last Update Date: 11/14/2025
Certification Date: 11/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7346 ELDORADO CT
MC LEAN VA
22102-2908
US

IV. Provider business mailing address

7346 ELDORADO CT
MC LEAN VA
22102-2908
US

V. Phone/Fax

Practice location:
  • Phone: 571-354-5971
  • Fax:
Mailing address:
  • Phone: 571-309-6004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number7809026578
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: