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General NPI Number Information
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NPI Number | 1447763842
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Entity Type | Organization
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Legal Business Name | AEDA ASSOCIATES, LLC
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Dates
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Enumeration Date | 11/08/2017
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Last Update Date | 11/08/2017
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Provider Practice Location Address
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Address Line | 10723 MAIN ST
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City | FAIRFAX
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State | VA
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Zip | 22030-6905
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Country | US
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Telephone | 703-615-7475
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Fax |
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Provider Business Mailing Address
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Address Line | 6239 SUMMER POND DR APT B
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City | CENTREVILLE
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State | VA
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Zip | 20121-4631
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Country | US
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Telephone | 703-615-7475
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Fax |
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Authorized Official
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Title or Position | MBR
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Name | MR. EUGENE ALLEN JR.
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Credential | CSAC,NCAC II
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Telephone | 703-615-7574
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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 | 0710103012
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License Number State | VA
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