Provider Demographics
NPI:1548807621
Name:INTROSPECTIVE HEALING PSYCHOTHERAPY PRACTICE, LLC
Entity type:Organization
Organization Name:INTROSPECTIVE HEALING PSYCHOTHERAPY PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOMINIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:AGYPT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:847-687-8774
Mailing Address - Street 1:300 N WASHINGTON ST STE 303A
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22046-3438
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 N WASHINGTON ST STE 303A
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22046-3438
Practice Address - Country:US
Practice Address - Phone:847-687-8774
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-07
Last Update Date:2019-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty