Healthcare Provider Details

I. General information

NPI: 1558552661
Provider Name (Legal Business Name): PAMELA JEAN MASANIELLO LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2007
Last Update Date: 08/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10372 DEMOCRACY LN APT D
FAIRFAX VA
22030-2522
US

IV. Provider business mailing address

10372 DEMOCRACY LN APT D
FAIRFAX VA
22030-2522
US

V. Phone/Fax

Practice location:
  • Phone: 703-591-2551
  • Fax: 703-591-2563
Mailing address:
  • Phone: 703-591-2551
  • Fax: 703-591-2563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701004207
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: