Healthcare Provider Details

I. General information

NPI: 1861369977
Provider Name (Legal Business Name): ABSOLUTE MENTAL HEALTH CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2025
Last Update Date: 10/22/2025
Certification Date: 10/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1930 OPITZ BLVD
WOODBRIDGE VA
22191-3304
US

IV. Provider business mailing address

1930 OPITZ BLVD
WOODBRIDGE VA
22191-3304
US

V. Phone/Fax

Practice location:
  • Phone: 571-398-2758
  • Fax: 888-315-4281
Mailing address:
  • Phone: 571-572-0050
  • Fax: 888-315-4281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. MAXIMO DE LA CRUZ
Title or Position: CHIEF DIRECTOR
Credential: BA-MA-QMHP
Phone: 571-572-0050