Healthcare Provider Details

I. General information

NPI: 1003561069
Provider Name (Legal Business Name): ANJA D. BLACKADAR LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2022
Last Update Date: 06/18/2024
Certification Date: 06/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4850 MARK CENTER DR
ALEXANDRIA VA
22311-1882
US

IV. Provider business mailing address

3901 WHISPERING LN
FALLS CHURCH VA
22041-1113
US

V. Phone/Fax

Practice location:
  • Phone: 703-746-3400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904015022
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: