Provider Demographics
NPI:1053347476
Name:COMMONWEALTH OF VIRGINIA DEPT OF MENTAL HEALTH AND NORTHERN VIRGINIA T
Entity type:Organization
Organization Name:COMMONWEALTH OF VIRGINIA DEPT OF MENTAL HEALTH AND NORTHERN VIRGINIA T
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FACILITY DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:DIORIO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, MPH
Authorized Official - Phone:703-323-4002
Mailing Address - Street 1:9901 BRADDOCK RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22032-1904
Mailing Address - Country:US
Mailing Address - Phone:703-323-4000
Mailing Address - Fax:703-323-4252
Practice Address - Street 1:9901 BRADDOCK RD
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22032-1904
Practice Address - Country:US
Practice Address - Phone:703-323-4000
Practice Address - Fax:703-323-4252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual DisabilitiesGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA49-6630-9Medicaid
VA701151Medicare PIN