Healthcare Provider Details

I. General information

NPI: 1568325553
Provider Name (Legal Business Name): MIA MACKENZIE SEBASTIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2025
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12007 SUNRISE VALLEY DR
RESTON VA
20191-3479
US

IV. Provider business mailing address

22904 BENSON TER
STERLING VA
20166-4332
US

V. Phone/Fax

Practice location:
  • Phone: 703-522-2089
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: