1225044258 NPI number — MARIE L DESJARDINS LCSW

Table of content: MARIE L DESJARDINS LCSW (NPI 1225044258)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225044258 NPI number — MARIE L DESJARDINS LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DESJARDINS
Provider First Name:
MARIE
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225044258
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/07/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21641 RIDGETOP CIR
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
STERLING
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20166-6597
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
571-258-3026
Provider Business Mailing Address Fax Number:
571-258-3032

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
801 CHILDRENS CENTER RD SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEESBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20175-2545
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-777-3485
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/31/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  0904004876 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 195259 . This is a "ANTHEM PROVIDER NUMBER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 254019 . This is a "KAISER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".