Healthcare Provider Details

I. General information

NPI: 1295252146
Provider Name (Legal Business Name): FIDELIS THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2017
Last Update Date: 08/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2555 CHAIN BRIDGE RD
VIENNA VA
22181-5517
US

IV. Provider business mailing address

11350 RANDOM HILLS RD FL 8
FAIRFAX VA
22030-6044
US

V. Phone/Fax

Practice location:
  • Phone: 703-474-6427
  • Fax:
Mailing address:
  • Phone: 702-474-6427
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number0701006683
License Number StateVA

VIII. Authorized Official

Name: DR. ELEANOR VINCENT
Title or Position: CEO/THERAPIST
Credential: EDD, LPC, CSAC
Phone: 703-474-6427