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General NPI Number Information
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NPI Number | 1295252146
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Entity Type | Organization
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Legal Business Name | FIDELIS THERAPY, LLC
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Dates
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Enumeration Date | 08/22/2017
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Last Update Date | 08/22/2017
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Provider Practice Location Address
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Address Line | 2555 CHAIN BRIDGE RD
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City | VIENNA
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State | VA
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Zip | 22181-5517
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Country | US
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Telephone | 703-474-6427
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Fax |
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Provider Business Mailing Address
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Address Line | 11350 RANDOM HILLS RD FL 8
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City | FAIRFAX
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State | VA
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Zip | 22030-6044
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Country | US
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Telephone | 702-474-6427
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Fax |
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Authorized Official
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Title or Position | CEO/THERAPIST
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Name | DR. ELEANOR VINCENT
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Credential | EDD, LPC, CSAC
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Telephone | 703-474-6427
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 0701006683
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License Number State | VA
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