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General NPI Number Information
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NPI Number | 1588654990
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Entity Type | Organization
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Legal Business Name | DEPARTMENT OF DEFENSE
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Dates
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Enumeration Date | 10/26/2005
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 14450 SMOKETOWN RD
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City | WOODBRIDGE
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State | VA
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Zip | 22192-4712
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Country | US
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Telephone | 703-576-1397
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Fax |
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Provider Business Mailing Address
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Address Line | 1949 POHICK CREEK CT
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City | WOODBRIDGE
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State | VA
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Zip | 22192-2428
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Country | US
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Telephone | 703-492-9112
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Fax |
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Authorized Official
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Title or Position | PROGRAM DIRECTOR
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Name | MS. SHELIA REDMOND
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Credential | MSW
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Telephone | 703-576-1403
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 0904004811
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License Number State | VA
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