Healthcare Provider Details

I. General information

NPI: 1154005692
Provider Name (Legal Business Name): SUSANNE COLLARES LCSW, CAADC, CSAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2023
Last Update Date: 03/28/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6910 RICHMOND HWY STE 110
ALEXANDRIA VA
22306-1850
US

IV. Provider business mailing address

4213 WALNEY RD
CHANTILLY VA
20151-2923
US

V. Phone/Fax

Practice location:
  • Phone: 703-660-8100
  • Fax:
Mailing address:
  • Phone: 703-502-7045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904013847
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: