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General NPI Number Information
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NPI Number | 1477323152
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Entity Type | Organization
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Legal Business Name | BROOKSIDE FAMILY THERAPY, LLC
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Dates
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Enumeration Date | 01/04/2024
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Last Update Date | 01/04/2024
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Provider Practice Location Address
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Address Line | 9105A OWENS DR STE 102
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City | MANASSAS PARK
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State | VA
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Zip | 20111-4852
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Country | US
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Telephone | 571-445-0265
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Fax | 855-755-7769
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Provider Business Mailing Address
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Address Line | 7118 KNOTTY OAK LN
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City | MANASSAS
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State | VA
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Zip | 20112-3235
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | KELLY AUSTIN
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Credential | LMFT
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Telephone | 571-331-9704
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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