Provider Demographics
NPI:1861983009
Name:TYSONS MENTAL HEALTH CENTER LLC
Entity type:Organization
Organization Name:TYSONS MENTAL HEALTH CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MEHDI
Authorized Official - Middle Name:
Authorized Official - Last Name:EBRAHIMI BOROUMAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-377-4626
Mailing Address - Street 1:450 WEST BROAD STREET
Mailing Address - Street 2:SUITE 304
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22046-3318
Mailing Address - Country:US
Mailing Address - Phone:703-270-5847
Mailing Address - Fax:703-270-5848
Practice Address - Street 1:450 WEST BROAD STREET
Practice Address - Street 2:SUITE 304
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22046-3318
Practice Address - Country:US
Practice Address - Phone:703-270-5847
Practice Address - Fax:703-270-5848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-23
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)