1104464924 NPI number — PSYCHIATRIC CENTER OF NORTHERN VIRGINIA

Table of content: (NPI 1104464924)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104464924 NPI number — PSYCHIATRIC CENTER OF NORTHERN VIRGINIA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PSYCHIATRIC CENTER OF NORTHERN VIRGINIA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104464924
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/09/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13617 QUERY MILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH POTOMAC
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20878-3967
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-213-3644
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4300 MONTGOMERY AVE STE 304A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BETHESDA
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20814-4444
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
202-417-6222
Provider Business Practice Location Address Fax Number:
240-477-7616
Provider Enumeration Date:
12/11/2019

Additional Information

Authorized Official

Authorized Official Last Name:
ASTRADA
Authorized Official First Name:
CARLOS
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
202-868-9001

Provider Taxonomy Codes

  • Taxonomy code: 2084B0040X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 740028400 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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