=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780834911
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OCCOQUAN COUNSELING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2008
-----------------------------------------------------
Last Update Date | 04/27/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12866 HARBOR DR
-----------------------------------------------------
City | WOODBRIDGE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22192-2921
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-494-4164
-----------------------------------------------------
Fax | 703-563-9304
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12866 HARBOR DR
-----------------------------------------------------
City | WOODBRIDGE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22192-2921
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-203-7535
-----------------------------------------------------
Fax | 703-563-9304
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER/MANAGER
-----------------------------------------------------
Name | KELLY FACCIOLA
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 703-203-7535
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 0904005064
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------