1184393159 NPI number — HOLISTIC PSYCHIATRY AND MEDICAL CENTER LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184393159 NPI number — HOLISTIC PSYCHIATRY AND MEDICAL CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HOLISTIC PSYCHIATRY AND MEDICAL CENTER LLC
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:
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:
1184393159
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
214 DETERMINATION DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STAFFORD
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22554-3366
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-917-5808
Provider Business Mailing Address Fax Number:
571-774-4123

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
556 GARRISONVILLE RD STE 210
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STAFFORD
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22554-7819
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-917-5808
Provider Business Practice Location Address Fax Number:
571-774-4123
Provider Enumeration Date:
09/12/2021

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
OWUSU
Authorized Official First Name:
DORIS
Authorized Official Middle Name:
CUDJOE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
571-315-3313

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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