Healthcare Provider Details

I. General information

NPI: 1780869149
Provider Name (Legal Business Name): TILMER O. ENGEBRETSON PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2008
Last Update Date: 01/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7927 JONES BRANCH DR SUITE #6125
MC LEAN VA
22102-3322
US

IV. Provider business mailing address

7927 JONES BRANCH DR SUITE #6125
MC LEAN VA
22102-3322
US

V. Phone/Fax

Practice location:
  • Phone: 571-633-0600
  • Fax: 703-992-0993
Mailing address:
  • Phone: 571-633-0600
  • Fax: 703-992-0993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810003165
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number0810003165
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number0810003165
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: