Provider Demographics
NPI:1457413098
Name:ALEXANDRIA CSB
Entity type:Organization
Organization Name:ALEXANDRIA CSB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MERCEDES
Authorized Official - Middle Name:WILSON
Authorized Official - Last Name:DALLAS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:703-838-6400
Mailing Address - Street 1:4906 SHARON RD
Mailing Address - Street 2:
Mailing Address - City:CAMP SPRINGS
Mailing Address - State:MD
Mailing Address - Zip Code:20748-2236
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:720 N SAINT ASAPH ST
Practice Address - Street 2:FOURTH FLOOR
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-1912
Practice Address - Country:US
Practice Address - Phone:703-838-6400
Practice Address - Fax:703-838-5070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810001425251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008746A25OtherMEDICARE
VA188512OtherANTHEM
VA0025OtherCARE FIRST BCBS
VA270291OtherAMERIGROUP
VA=========002OtherTRICARE