Healthcare Provider Details

I. General information

NPI: 1295875375
Provider Name (Legal Business Name): ADOLESCENT AND FAMILY GROWTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 08/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8000 FORBES PL SUITE 201
SPRINGFIELD VA
22151-2200
US

IV. Provider business mailing address

8000 FORBES PL SUITE 201
SPRINGFIELD VA
22151-2200
US

V. Phone/Fax

Practice location:
  • Phone: 703-425-9200
  • Fax: 703-425-9206
Mailing address:
  • Phone: 703-425-9200
  • Fax: 703-425-9206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number24203001
License Number StateVA

VIII. Authorized Official

Name: JERMAINE H. JOHNSON
Title or Position: EXECUTIVE DIRECTOR
Credential: MS, MFT
Phone: 703-425-9200