Healthcare Provider Details

I. General information

NPI: 1689031122
Provider Name (Legal Business Name): HOPESPRING CHILD & FAMILY CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2016
Last Update Date: 01/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1497 CHAIN BRIDGE RD STE 103
MC LEAN VA
22101-5728
US

IV. Provider business mailing address

24981 WATERDOCK DR
STONE RIDGE VA
20105-5607
US

V. Phone/Fax

Practice location:
  • Phone: 410-241-2520
  • Fax: 410-442-1075
Mailing address:
  • Phone: 410-241-2520
  • Fax: 410-442-1075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0701005996
License Number StateVA

VIII. Authorized Official

Name: DR. MI-KYONG MONICA KWON
Title or Position: OWNER/DIRECTOR
Credential: PH.D., LPC, LCPC
Phone: 410-241-2520