Healthcare Provider Details

I. General information

NPI: 1255724936
Provider Name (Legal Business Name): PHYLLIS MILLER PALOMBI MS, LMFT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2015
Last Update Date: 03/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11524 HEMINGWAY DR
RESTON VA
20194-1252
US

IV. Provider business mailing address

11524 HEMINGWAY DR
RESTON VA
20194-1252
US

V. Phone/Fax

Practice location:
  • Phone: 703-435-7686
  • Fax: 703-563-9181
Mailing address:
  • Phone: 703-435-7686
  • Fax: 703-563-9181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number0701001061
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberPRC13615
License Number StateDC
# 3
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number0717000212
License Number StateVA

VIII. Authorized Official

Name: PHYLLIS MILLER PALOMBI
Title or Position: FAMILY THERAPIST
Credential: M.S.,LPC, LMFT
Phone: 703-435-7686