=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043459621
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOLLY CHALONER MASTORAS LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2009
-----------------------------------------------------
Last Update Date | 11/20/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 43130 AMBERWOOD PLZ SUITE 140
-----------------------------------------------------
City | SOUTH RIDING
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20152-4105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-348-0030
-----------------------------------------------------
Fax | 703-542-7770
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 43130 AMBERWOOD PLZ SUITE 140
-----------------------------------------------------
City | SOUTH RIDING
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20152-4105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-348-0030
-----------------------------------------------------
Fax | 703-542-7770
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 0701004457
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------