Healthcare Provider Details

I. General information

NPI: 1861292849
Provider Name (Legal Business Name): METKEL B RUSSOM MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2025
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12007 SUNRISE VALLEY DR STE 120
RESTON VA
20191-3460
US

IV. Provider business mailing address

12007 SUNRISE VALLEY DR STE 120
RESTON VA
20191-3460
US

V. Phone/Fax

Practice location:
  • Phone: 571-977-6870
  • Fax: 703-672-7001
Mailing address:
  • Phone: 571-977-6870
  • Fax: 703-672-7001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: