Healthcare Provider Details

I. General information

NPI: 1346340403
Provider Name (Legal Business Name): RITA THERESA MAISE I LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RITA THERESA MAISWINKLE I MSW, LCSW

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 07/31/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13649 OFFICE PL #102
WOODBRIDGE VA
22192-4215
US

IV. Provider business mailing address

10125 WOOD GREEN WAY
BURKE VA
22015-2714
US

V. Phone/Fax

Practice location:
  • Phone: 703-670-5738
  • Fax: 703-670-8213
Mailing address:
  • Phone: 703-503-7849
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904001261
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: