Healthcare Provider Details

I. General information

NPI: 1134812910
Provider Name (Legal Business Name): NICOLE MARSHALL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2023
Last Update Date: 05/30/2023
Certification Date: 05/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14225 SULLYFIELD CIR STE A
CHANTILLY VA
20151-1688
US

IV. Provider business mailing address

14225 SULLYFIELD CIR STE A
CHANTILLY VA
20151-1688
US

V. Phone/Fax

Practice location:
  • Phone: 703-263-0215
  • Fax:
Mailing address:
  • Phone: 703-263-0215
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904014904
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: