MEDICARE: DR. LINDA DOMENICA FAMA PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	0810003444	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	352673	OTHER	VA	ANTHEM BCBS

General Provider Information

NPI Number	:	1013015999
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LINDA DOMENICA FAMA PHD

Provider Business Mailing Address
First Line	:	313 PARK AVE STE 203
Second Line	:
City	:	FALLS CHURCH
State	:	VA
Zip	:	22046-3303
Country	:	US
Telephone Number	:	703-891-9505
Fax Number	:

Provider Business Practice Location Address
First Line	:	313 PARK AVE STE 203
Second Line	:
City	:	FALLS CHURCH
State	:	VA
Zip	:	22046-3303
Country	:	US
Telephone Number	:	703-891-9505
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/21/2006
Last Update Date	:	07/18/2008

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