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General NPI Number Information
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NPI Number | 1003967563
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Entity Type | Organization
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Legal Business Name | EPHESIANS LIFE MINISTRIES
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Dates
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Enumeration Date | 01/12/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 260 CEDAR LN SE # B
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City | VIENNA
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State | VA
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Zip | 22180-6698
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Country | US
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Telephone | 703-204-0250
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Fax |
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Provider Business Mailing Address
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Address Line | 1620 ELTON RD STE 204
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City | SILVER SPRING
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State | MD
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Zip | 20903-1760
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Country | US
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Telephone | 301-439-7191
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Fax |
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Authorized Official
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Title or Position | THERAPIST
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Name | MRS. SUNNY S PARK
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Credential | L.C.S.W.-C
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Telephone | 240-472-3216
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 11220
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License Number State | MD
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 0904005471
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License Number State | VA
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