=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427567965
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIANA BERMUDEZ PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2017
-----------------------------------------------------
Last Update Date | 09/27/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3260 WILSON BLVD STE 21C
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22201-4423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-782-8763
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3511 22ND ST N
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22207-3828
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-868-3439
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 0701005719
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------