Provider Demographics
NPI:1366743460
Name:JOHN JOSEPH GUALTIERI, PH.D., P.C.
Entity type:Organization
Organization Name:JOHN JOSEPH GUALTIERI, PH.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:GUALTIERI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:703-790-8111
Mailing Address - Street 1:1515 CHAIN BRIDGE RD
Mailing Address - Street 2:SUITE G14
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-4451
Mailing Address - Country:US
Mailing Address - Phone:703-790-8111
Mailing Address - Fax:703-356-1453
Practice Address - Street 1:1515 CHAIN BRIDGE RD
Practice Address - Street 2:SUITE G14
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-4451
Practice Address - Country:US
Practice Address - Phone:703-790-8111
Practice Address - Fax:703-356-1453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-05
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810001429103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
468810Medicare PIN