=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639932577
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POLARIS COUNSELING CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2024
-----------------------------------------------------
Last Update Date | 02/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5274 LYNGATE CT
-----------------------------------------------------
City | BURKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22015-1688
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-539-5914
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10705 PAYNES CHURCH DR
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22032-2940
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DAWN WEISS SMITH
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 703-539-5914
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------