Healthcare Provider Details

I. General information

NPI: 1023170180
Provider Name (Legal Business Name): THERESA M. SHALTANIS M.A., LPC, LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10379B DEMOCRACY LN
FAIRFAX VA
22030-2505
US

IV. Provider business mailing address

10379B DEMOCRACY LN
FAIRFAX VA
22030-2505
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 TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0717000629
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701002445
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: