MEDICARE: LIFESPAN COUNSELING SERVICES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	0904006801	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	12093630	OTHER	VA	CAQH

General Provider Information

NPI Number	:	1407173248
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFESPAN COUNSELING SERVICES, LLC

Provider Business Mailing Address
First Line	:	5104 COLERIDGE DR
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22032-2420
Country	:	US
Telephone Number	:	703-965-8712
Fax Number	:

Provider Business Practice Location Address
First Line	:	8500 EXECUTIVE PARK AVE STE 204
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22031-2253
Country	:	US
Telephone Number	:	703-876-8480
Fax Number	:

Authorized Official
Title or Position	:	SOCIAL WORKER
Name	:	MS. DANIELLE C NICHOLSON
Credential	:	LCSW
Telephone Number	:	703-490-9681

Provider Enumeration Date	:	05/03/2010
Last Update Date	:	04/29/2015

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