Healthcare Provider Details

I. General information

NPI: 1679080105
Provider Name (Legal Business Name): CHRISTIE WILLETT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2018
Last Update Date: 01/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1651 OLD MEADOW RD
MC LEAN VA
22102-4311
US

IV. Provider business mailing address

5916 OLD SOLOMONS ISLAND RD
TRACYS LANDING MD
20779-2107
US

V. Phone/Fax

Practice location:
  • Phone: 703-564-1639
  • Fax:
Mailing address:
  • Phone: 240-271-4431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: