Organization
FOUNTAIN OF LIFE LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. LISA KLEWICKI PH.D. (CLINICAL PSYCHOLOGIST)
(571) 277-4919
Entity
Organization
Contact information
Practice address
450 W BROAD ST STE 211, FALLS CHURCH, VA 22046-3318
(571) 277-4919
(703) 241-1122
Mailing address
450 W BROAD ST STE 211, FALLS CHURCH, VA 22046-3318
(571) 277-4919
(703) 241-1122
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
0810002980
VA
Other
Enumeration date
03/14/2017
Last updated
03/14/2017
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