Healthcare Provider Details

I. General information

NPI: 1548928104
Provider Name (Legal Business Name): DEMETRIES L NORTH LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2021
Last Update Date: 12/02/2021
Certification Date: 12/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 NEW JERSEY AVE SE STE 500
WASHINGTON DC
20003-3326
US

IV. Provider business mailing address

2200 WILSON BLVD. STE., 102- #43
ARLINGTON VA
22201
US

V. Phone/Fax

Practice location:
  • Phone: 202-279-1817
  • Fax: 202-617-2985
Mailing address:
  • Phone: 571-446-1991
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0704014115
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: