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General NPI Number Information
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NPI Number | 1417469974
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Entity Type | Organization
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Legal Business Name | LIFELINE PSYCHOTHERAPY SERVICES
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Dates
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Enumeration Date | 10/24/2017
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Last Update Date | 10/24/2017
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Provider Practice Location Address
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Address Line | 11350 RANDOM HILLS RD STE 800
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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 | 703-409-6258
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Fax |
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Provider Business Mailing Address
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Address Line | 12646 HERON RIDGE DR
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City | FAIRFAX
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State | VA
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Zip | 22030-6638
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Country | US
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Telephone | 703-409-6258
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | HOANG OANH RODGERS
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Credential | LMFT, LPC
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Telephone | 703-409-6258
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 0710000893
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 0701002418
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License Number State | VA
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Taxonomy #3
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 0717000800
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License Number State | VA
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