Provider Demographics
NPI:1053786962
Name:THE CENTER FOR SELF-DEVELOPMENT, LLC
Entity type:Organization
Organization Name:THE CENTER FOR SELF-DEVELOPMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HAGEN, LPC
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:703-433-1553
Mailing Address - Street 1:2 PIDGEON HILL DR
Mailing Address - Street 2:SUITE 450
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20165-6145
Mailing Address - Country:US
Mailing Address - Phone:703-433-1553
Mailing Address - Fax:703-433-1558
Practice Address - Street 1:2 PIDGEON HILL DR
Practice Address - Street 2:SUITE 450
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20165-6145
Practice Address - Country:US
Practice Address - Phone:703-433-1553
Practice Address - Fax:703-433-1558
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE CENTER FOR SELF-DEVELOPMENT, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-12-03
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701004125251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4945247Medicaid