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General NPI Number Information
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NPI Number | 1962789495
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Entity Type | Organization
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Legal Business Name | LIFEWORKS OUTREACH SERVICES, INC.
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Dates
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Enumeration Date | 11/11/2011
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Last Update Date | 11/11/2011
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Provider Practice Location Address
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Address Line | 4300 RIDGEWOOD CENTER DR UNIT A
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City | WOODBRIDGE
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State | VA
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Zip | 22192-5307
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Country | US
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Telephone | 703-580-7210
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Fax | 703-580-7213
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Provider Business Mailing Address
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Address Line | 4300 RIDGEWOOD CENTER DR UNIT A
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City | WOODBRIDGE
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State | VA
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Zip | 22192-5307
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Country | US
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Telephone | 703-580-7210
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Fax | 703-580-7213
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Authorized Official
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Title or Position | CLINICAL DIRECTOR/OWNER
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Name | MRS. MAUREEN VICTORIA FANNIN
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Credential | LCSW
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Telephone | 703-580-7210
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 1039-05-001
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License Number State | VA
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