=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043171523
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VALLEY PRIMARY & BEHAVIORAL HEALTH CLINIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/24/2025
-----------------------------------------------------
Last Update Date | 11/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10625 MCCORMICK FARM DR
-----------------------------------------------------
City | MANASSAS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20110-6934
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-306-8614
-----------------------------------------------------
Fax | 202-519-8044
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10625 MCCORMICK FARM DR
-----------------------------------------------------
City | MANASSAS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20110-6934
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-306-8614
-----------------------------------------------------
Fax | 202-519-8044
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | THERESA JUANA-KAMANDA
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 571-306-8614
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LC1500X
-----------------------------------------------------
Taxonomy Name | Community Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------