Healthcare Provider Details

I. General information

NPI: 1124759303
Provider Name (Legal Business Name): LENA MARIE DERHALLY LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2022
Last Update Date: 06/20/2022
Certification Date: 06/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3808 FULTON ST NW
WASHINGTON DC
20007-1344
US

IV. Provider business mailing address

3808 FULTON ST NW
WASHINGTON DC
20007-1344
US

V. Phone/Fax

Practice location:
  • Phone: 512-560-7277
  • Fax:
Mailing address:
  • Phone: 512-560-7277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License NumberPRC14540
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: