=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093531758
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VALCAE GROUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/26/2024
-----------------------------------------------------
Last Update Date | 11/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9225 RAINBOW FALLS DR
-----------------------------------------------------
City | BRISTOW
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20136-2136
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-358-9705
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9225 RAINBOW FALLS DR
-----------------------------------------------------
City | BRISTOW
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20136-2136
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BH THERAPIST
-----------------------------------------------------
Name | VICTOR MIRANDA
-----------------------------------------------------
Credential | M.ED, LPC
-----------------------------------------------------
Telephone | 571-358-9705
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------