=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679177224
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEUROPSYCHOLOGY ASSOCIATES OF FAIRFAX VIRGINIA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/24/2020
-----------------------------------------------------
Last Update Date | 11/24/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3020 HAMAKER CT STE 103
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22031-2220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-876-0966
-----------------------------------------------------
Fax | 703-876-1628
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3020 HAMAKER CT STE 103
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22031-2220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-876-0966
-----------------------------------------------------
Fax | 703-876-1628
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. CYNTHIA L SULLIVAN
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 703-851-7109
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------