Provider Demographics
NPI:1699201749
Name:FAIRFAX MENTAL HEALTH & WELLNESS
Entity type:Organization
Organization Name:FAIRFAX MENTAL HEALTH & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:SHORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-996-6164
Mailing Address - Street 1:3554 CHAIN BRIDGE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-2709
Mailing Address - Country:US
Mailing Address - Phone:703-896-7628
Mailing Address - Fax:703-890-2359
Practice Address - Street 1:3554 CHAIN BRIDGE RD STE 200
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-2709
Practice Address - Country:US
Practice Address - Phone:703-896-7628
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty