=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053601450
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEARNING ALLIANCE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2011
-----------------------------------------------------
Last Update Date | 04/19/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3959 PENDER DR
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22030-6041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-899-7672
-----------------------------------------------------
Fax | 703-685-6843
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6471 FENESTRA CT
-----------------------------------------------------
City | BURKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22015-3569
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-899-7672
-----------------------------------------------------
Fax | 703-861-6843
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MS. CHRISTINA M. EPPINK
-----------------------------------------------------
Credential | B.C.B.A.
-----------------------------------------------------
Telephone | 703-899-7672
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------