=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215327309
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BALLSTON PSYCHOLOGY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2015
-----------------------------------------------------
Last Update Date | 01/28/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4141 N HENDERSON RD PLAZA LEVEL, SUITE 3
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22203-2486
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-338-4488
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4473
-----------------------------------------------------
City | FALLS CHURCH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22044-0473
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-338-4488
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DAVID A KOHLS
-----------------------------------------------------
Credential | PSYD
-----------------------------------------------------
Telephone | 571-338-4488
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 0810003893
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------