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General NPI Number Information
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NPI Number | 1386727329
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Entity Type | Organization
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Legal Business Name | ICON COMMUNITY SERVICES, INC
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Dates
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Enumeration Date | 10/23/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1240 N PITT ST SUITE LL
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City | ALEXANDRIA
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State | VA
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Zip | 22314-5600
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Country | US
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Telephone | 703-548-4048
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Fax | 703-548-0198
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Provider Business Mailing Address
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Address Line | 1240 N PITT ST SUITE LL
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City | ALEXANDRIA
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State | VA
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Zip | 22314-5600
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Country | US
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Telephone | 703-548-4048
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Fax | 703-548-0198
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MS. ROBYN M FITZGERALD
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Credential |
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Telephone | 703-548-4048
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number | 06303001
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License Number State | VA
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