Provider Demographics
NPI:1194566117
Name:MENTAL HEALTH THERAPY CENTER - NORTHERN VIRGINIA, LLC
Entity type:Organization
Organization Name:MENTAL HEALTH THERAPY CENTER - NORTHERN VIRGINIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIVISION CFO
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:GINGRAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-228-4901
Mailing Address - Street 1:10721 MAIN ST STE 1300
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-6902
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10721 MAIN ST STE 1300
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-6902
Practice Address - Country:US
Practice Address - Phone:703-536-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-04
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)