Healthcare Provider Details

I. General information

NPI: 1245263961
Provider Name (Legal Business Name): THERESA ANN LICHTMAN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 05/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21000 EDUCATION CT
BROADLANDS VA
20148
US

IV. Provider business mailing address

21000 EDUCATION CT
BROADLANDS VA
20148-5526
US

V. Phone/Fax

Practice location:
  • Phone: 572-252-2214
  • Fax:
Mailing address:
  • Phone: 572-252-2214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810002799
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: