=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790926426
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUSAN KINKEAD-ACREE, MD, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2009
-----------------------------------------------------
Last Update Date | 10/23/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1320 OLD CHAIN BRIDGE RD SUITE 420
-----------------------------------------------------
City | MC LEAN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22101-3956
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-992-6537
-----------------------------------------------------
Fax | 703-992-6539
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1485 CHAIN BRIDGE RD SUITE 204
-----------------------------------------------------
City | MC LEAN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22101-4501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-992-6537
-----------------------------------------------------
Fax | 703-992-6539
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. SUSAN KINKEAD-ACREE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 703-992-6537
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number | 0101244394
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------