Healthcare Provider Details

I. General information

NPI: 1649088527
Provider Name (Legal Business Name): DC PSYCHIATRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2024
Last Update Date: 12/23/2024
Certification Date: 12/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 TOWN CENTER DR STE 420
RESTON VA
20190-3240
US

IV. Provider business mailing address

PO BOX 710015
HERNDON VA
20171-0015
US

V. Phone/Fax

Practice location:
  • Phone: 703-869-5361
  • Fax: 703-957-3625
Mailing address:
  • Phone: 703-869-5361
  • Fax: 703-957-3625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. CORDELIA NIEKETIEN-TAWARI, DNP, APRN-BC, LNP
Title or Position: CEO
Credential: DNP APRN-BC LNP
Phone: 703-869-5361