Healthcare Provider Details

I. General information

NPI: 1033812045
Provider Name (Legal Business Name): COLLABORATIVE SUPPORT PSYCHOLOGICAL SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2023
Last Update Date: 03/27/2023
Certification Date: 03/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1224 BISHOPSGATE WAY
RESTON VA
20194-1414
US

IV. Provider business mailing address

1224 BISHOPSGATE WAY
RESTON VA
20194-1414
US

V. Phone/Fax

Practice location:
  • Phone: 703-915-3025
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: ANETA KERN
Title or Position: PSYCHOLOGIST
Credential: PHD
Phone: 703-915-3025