Healthcare Provider Details

I. General information

NPI: 1649196189
Provider Name (Legal Business Name): CARDINAL CARE BEHAVIORAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11921 FREEDOM DRIVE 2 FOUNTIAN SQUARE SUITE 550
RESTON VA
20190
US

IV. Provider business mailing address

11921 FREEDOM DR STE 550
RESTON VA
20190-5635
US

V. Phone/Fax

Practice location:
  • Phone: 310-483-2662
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: ROSHANAK SAFIARDESTANI
Title or Position: BEHAVIOR ANALYST
Credential: BCBA
Phone: 310-483-2662