=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790906618
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALISA MARIE VANLANDINGHAM PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2007
-----------------------------------------------------
Last Update Date | 09/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9300 DEWITT LOOP
-----------------------------------------------------
City | FORT BELVOIR
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22060-5285
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-231-3224
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9469 LAPSTRAKE LN
-----------------------------------------------------
City | BURKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22015-4214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-220-6502
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 1095
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------