Healthcare Provider Details

I. General information

NPI: 1043293012
Provider Name (Legal Business Name): MARY MISCHTSCHUK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 10/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12721 DARBY BROOK CT STE 102
WOODBRIDGE VA
22192-2408
US

IV. Provider business mailing address

4300 KING ST SUITE 130
ALEXANDRIA VA
22302-1503
US

V. Phone/Fax

Practice location:
  • Phone: 703-879-5144
  • Fax: 703-879-5860
Mailing address:
  • Phone: 703-879-5144
  • Fax: 703-879-5860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number10740
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC50081376
License Number StateDC
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904005510
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: