1215360532 NPI number — PHYLLIS M FORTUNATO MARTIN LPC

Table of content: PHYLLIS M FORTUNATO MARTIN LPC (NPI 1215360532)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215360532 NPI number — PHYLLIS M FORTUNATO MARTIN LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTIN
Provider First Name:
PHYLLIS
Provider Middle Name:
M FORTUNATO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

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:
1215360532
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10400 EATON PL
Provider Second Line Business Mailing Address:
SUITE 110
Provider Business Mailing Address City Name:
FAIRFAX
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22030-2208
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-509-7412
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10400 EATON PL
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
FAIRFAX
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22030-2208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-509-7412
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/11/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  0701003077 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com