=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457407009
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WOODBRIDGE PSYCHOLOGICAL ASSOCIATES, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2200 OPITZ BLVD STE 105B
-----------------------------------------------------
City | WOODBRIDGE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22191-3342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-491-0042
-----------------------------------------------------
Fax | 703-491-9200
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2200 OPITZ BLVD STE 105B
-----------------------------------------------------
City | WOODBRIDGE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22191-3342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-491-0042
-----------------------------------------------------
Fax | 703-491-9200
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. WILLIAM JOSEPH STEJSKAL
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 703-491-0042
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 0810011635
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------