Healthcare Provider Details

I. General information

NPI: 1265981054
Provider Name (Legal Business Name): ANGELA MAYO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2016
Last Update Date: 09/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1495 CHAIN BRIDGE RD SUITE 300
MC LEAN VA
22101-5727
US

IV. Provider business mailing address

1495 CHAIN BRIDGE RD. SUITE 300
MCLEAN VA
22101
US

V. Phone/Fax

Practice location:
  • Phone: 815-579-9578
  • Fax:
Mailing address:
  • Phone: 815-579-9578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904009624
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: