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General NPI Number Information
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NPI Number | 1639530629
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Entity Type | Organization
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Legal Business Name | NURTURE CHILD AND FAMILY, PLLC
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Dates
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Enumeration Date | 03/17/2016
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Last Update Date | 03/17/2016
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Provider Practice Location Address
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Address Line | 1319 VINCENT PL
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City | MC LEAN
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State | VA
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Zip | 22101-3615
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Country | US
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Telephone | 703-341-5995
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Fax | 703-341-5995
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Provider Business Mailing Address
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Address Line | 1319 VINCENT PL
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City | MC LEAN
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State | VA
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Zip | 22101-3615
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Country | US
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Telephone | 703-341-5995
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Fax | 703-341-5995
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Authorized Official
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Title or Position | MEMBER
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Name | MARK STEVEN GARDNER
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Credential | LCSW
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Telephone | 703-341-5995
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number | 080003355
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 904005796
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License Number State | VA
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