MEDICARE: LSN PSYCHOLOGICAL SERVICES, LLC

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	0810005240	VA

General Provider Information

NPI Number	:	1619415817
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LSN PSYCHOLOGICAL SERVICES, LLC

Provider Business Mailing Address
First Line	:	11760 SUNRISE VALLEY DR
Second Line	:	APT 814
City	:	RESTON
State	:	VA
Zip	:	20191-1411
Country	:	US
Telephone Number	:	703-677-8633
Fax Number	:

Provider Business Practice Location Address
First Line	:	1900 CAMPUS COMMONS DR
Second Line	:	SUITE 100
City	:	RESTON
State	:	VA
Zip	:	20191-1561
Country	:	US
Telephone Number	:	703-677-8633
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DR. LESLIE ERIN STELLJES NANSON
Credential	:	PSYD
Telephone Number	:	703-677-8633

Provider Enumeration Date	:	02/08/2017
Last Update Date	:	02/08/2017

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