Healthcare Provider Details

I. General information

NPI: 1346632155
Provider Name (Legal Business Name): JOHN MILLIKIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2015
Last Update Date: 03/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1984 ISAAC NEWTON SQ W 204
RESTON VA
20190-5038
US

IV. Provider business mailing address

1984 ISAAC NEWTON SQ WEST 204
RESTON VA
20190
US

V. Phone/Fax

Practice location:
  • Phone: 703-464-9700
  • Fax: 703-464-8669
Mailing address:
  • Phone: 703-464-9700
  • Fax: 703-464-8669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0717-001019
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: