Healthcare Provider Details

I. General information

NPI: 1568790624
Provider Name (Legal Business Name): PASTORAL COUNSELING OF NORTHERN VIRGINIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2009
Last Update Date: 12/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205 DOLLEY MADISON BLVD
MC LEAN VA
22101-3019
US

IV. Provider business mailing address

4094 MAJESTIC LN
FAIRFAX VA
22033-2104
US

V. Phone/Fax

Practice location:
  • Phone: 703-449-1944
  • Fax: 703-356-9119
Mailing address:
  • Phone: 703-449-1944
  • Fax: 703-356-9119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0717000185
License Number StateVA

VIII. Authorized Official

Name: DR. GARY L HULME
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 703-449-1944