Healthcare Provider Details

I. General information

NPI: 1013980523
Provider Name (Legal Business Name): KENNETH RICHARD THAU M.S.W., J.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7969 SEQUOIA PARK WAY
BRISTOW VA
20136-1286
US

IV. Provider business mailing address

PO BOX 807
BRISTOW VA
20136-0807
US

V. Phone/Fax

Practice location:
  • Phone: 202-320-5322
  • Fax:
Mailing address:
  • Phone: 202-320-5322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904003262
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: