=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073222311
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NOVA PSYCH & WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2022
-----------------------------------------------------
Last Update Date | 11/15/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10306 EATON PL STE 300
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22030-2201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-783-2474
-----------------------------------------------------
Fax | 703-783-7459
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10306 EATON PL STE 300
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22030-2201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | MELANIE YOUSEFI
-----------------------------------------------------
Credential | DNP, PMHNP-BC
-----------------------------------------------------
Telephone | 703-783-2474
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------