Healthcare Provider Details

I. General information

NPI: 1386727824
Provider Name (Legal Business Name): DIANE HOFSTADTER LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 10/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 PARK ST NE SUITE 10A
VIENNA VA
22180-4603
US

IV. Provider business mailing address

5714 MACKENZIE ST
CENTREVILLE VA
20120-1422
US

V. Phone/Fax

Practice location:
  • Phone: 405-818-6024
  • Fax:
Mailing address:
  • Phone: 405-818-6024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1667
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701004826
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: