Healthcare Provider Details

I. General information

NPI: 1942682075
Provider Name (Legal Business Name): DEEPA PATEL LCSW, CSOTP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2015
Last Update Date: 04/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5415 BACKLICK RD # C
SPRINGFIELD VA
22151-3915
US

IV. Provider business mailing address

PO BOX 523421 ATTN CARMEN WYMAN
SPRINGFIELD VA
22152-5421
US

V. Phone/Fax

Practice location:
  • Phone: 703-750-1714
  • Fax: 703-339-5651
Mailing address:
  • Phone: 703-339-6471
  • Fax: 703-339-5651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0812000610
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904007859
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: