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General NPI Number Information
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NPI Number | 1558542928
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Entity Type | Organization
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Legal Business Name | STELLA BRIZUELA-MORENO DBA INTERNATIONAL CONSULTING CENTER
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Dates
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Enumeration Date | 11/14/2007
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Last Update Date | 07/26/2011
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Provider Practice Location Address
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Address Line | 8300 BOONE BLVD SUITE 500
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City | VIENNA
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State | VA
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Zip | 22182-2626
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Country | US
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Telephone | 703-255-1600
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Fax | 703-652-7641
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Provider Business Mailing Address
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Address Line | 8300 BOONE BLVD SUITE 500
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City | VIENNA
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State | VA
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Zip | 22182-2626
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Country | US
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Telephone | 703-255-1600
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Fax | 703-652-7641
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | DR. STELLA BRIZUELA-MORENO
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Credential | PH.D.
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Telephone | 703-255-1600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Psychologist
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License Number | 0718000189
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License Number State | VA
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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 | 0717000665
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License Number State | VA
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Taxonomy #3
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number | PRC 312
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License Number State | DC
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