Healthcare Provider Details

I. General information

NPI: 1215316138
Provider Name (Legal Business Name): BRAIN INJURY SERVCIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2015
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date: 02/08/2024
Reactivation Date: 02/29/2024

III. Provider practice location address

8136 OLD KEENE MILL RD SUITE B102
SPRINGFIELD VA
22152-1850
US

IV. Provider business mailing address

8136 OLD KEENE MILL RD SUITE B102
SPRINGFIELD VA
22152-1850
US

V. Phone/Fax

Practice location:
  • Phone: 703-451-8881
  • Fax: 703-451-8820
Mailing address:
  • Phone: 703-451-8881
  • Fax: 703-451-8820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0301X
TaxonomyBrain Injury Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: DONNA A. MELTZER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 703-451-8881