Provider Demographics
NPI:1366063992
Name:OLD TOWN PROFESSIONAL PSYCHOLOGY
Entity type:Organization
Organization Name:OLD TOWN PROFESSIONAL PSYCHOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:SUNDAR
Authorized Official - Middle Name:
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:540-931-5238
Mailing Address - Street 1:411 1/2 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-2311
Mailing Address - Country:US
Mailing Address - Phone:540-931-5238
Mailing Address - Fax:
Practice Address - Street 1:411 1/2 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-2311
Practice Address - Country:US
Practice Address - Phone:571-327-0194
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-05
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalystGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysisGroup - Multi-Specialty