Healthcare Provider Details

I. General information

NPI: 1982663142
Provider Name (Legal Business Name): DAVID A SHOSTAK PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 08/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8348 TRAFORD LANE STE 302
SPRINGFIELD VA
22152-1650
US

IV. Provider business mailing address

8348 TRAFORD LANE STE 302
SPRINGFIELD VA
22152-1650
US

V. Phone/Fax

Practice location:
  • Phone: 703-451-8816
  • Fax: 703-451-9766
Mailing address:
  • Phone: 703-451-8816
  • Fax: 703-451-9766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number0810000940
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: