Healthcare Provider Details

I. General information

NPI: 1104395110
Provider Name (Legal Business Name): CROSSROAD CLINICS PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2018
Last Update Date: 11/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12359 SUNRISE VALLEY DR STE 320
RESTON VA
20191-3463
US

IV. Provider business mailing address

12359 SUNRISE VALLEY DR STE 320
RESTON VA
20191-3463
US

V. Phone/Fax

Practice location:
  • Phone: 703-596-4796
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code364SP0813X
TaxonomyGeropsychiatric Psychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number State

VIII. Authorized Official

Name: DR. MADAN KUMAR UPRETY
Title or Position: CEO
Credential: MD
Phone: 703-596-4796