Provider Demographics
NPI:1962789495
Name:LIFEWORKS OUTREACH SERVICES, INC.
Entity type:Organization
Organization Name:LIFEWORKS OUTREACH SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:VICTORIA
Authorized Official - Last Name:FANNIN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:703-580-7210
Mailing Address - Street 1:4300 RIDGEWOOD CENTER DR UNIT A
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-5307
Mailing Address - Country:US
Mailing Address - Phone:703-580-7210
Mailing Address - Fax:703-580-7213
Practice Address - Street 1:4300 RIDGEWOOD CENTER DR UNIT A
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-5307
Practice Address - Country:US
Practice Address - Phone:703-580-7210
Practice Address - Fax:703-580-7213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-11
Last Update Date:2011-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1039-05-001101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty