Provider Demographics
NPI:1447348198
Name:FELLENBERG, STEPHANIE (PSYD)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:FELLENBERG
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2239F TACKETTS MILL DR
Mailing Address - Street 2:PSYCHOLOGICAL & LIFE SKILLS ASSOC PC
Mailing Address - City:LAKE RIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192
Mailing Address - Country:US
Mailing Address - Phone:703-490-0336
Mailing Address - Fax:703-490-4525
Practice Address - Street 1:2239F TACKETTS MILL DR
Practice Address - Street 2:PSYCHOLOGICAL & LIFE SKILLS ASSOC PC
Practice Address - City:LAKE RIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192
Practice Address - Country:US
Practice Address - Phone:703-490-0336
Practice Address - Fax:703-490-4525
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810003529103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA178511OtherANTHEM BCBS
VA23570022OtherCAREFIRST
VA23570022OtherCAREFIRST