Healthcare Provider Details

I. General information

NPI: 1912302555
Provider Name (Legal Business Name): NOVA PSYCHIATRIST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2014
Last Update Date: 10/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12359 SUNRISE VALLEY DR SUITE 320
RESTON VA
20191-3462
US

IV. Provider business mailing address

12359 SUNRISE VALLEY DR SUITE 320
RESTON VA
20191-3462
US

V. Phone/Fax

Practice location:
  • Phone: 703-596-4796
  • Fax: 703-435-6747
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code364SP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number State

VIII. Authorized Official

Name: DR. MADAN KUMAR UPRETY
Title or Position: MEMBER
Credential: M.D.
Phone: 703-596-4796