Basic Information
| Provider Information | |||||||||
| NPI: | 1457413098 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALEXANDRIA CSB | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4906 SHARON RD | ||||||||
| Address2: | |||||||||
| City: | CAMP SPRINGS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207482236 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 720 N SAINT ASAPH ST | ||||||||
| Address2: | FOURTH FLOOR | ||||||||
| City: | ALEXANDRIA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 223141912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038386400 | ||||||||
| FaxNumber: | 7038385070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | DALLAS | ||||||||
| AuthorizedOfficialFirstName: | MERCEDES | ||||||||
| AuthorizedOfficialMiddleName: | WILSON | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL PSYCHOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 7038386400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PH.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 0810001425 | VA | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 008746A25 | 01 | VA | MEDICARE | OTHER | 188512 | 01 | VA | ANTHEM | OTHER | 0025 | 01 | VA | CARE FIRST BCBS | OTHER | 270291 | 01 | VA | AMERIGROUP | OTHER |