=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083288393
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SERENA CHU PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2021
-----------------------------------------------------
Last Update Date | 11/13/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6001 EXECUTIVE BOULEVARD
-----------------------------------------------------
City | BETHESDA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20892-2457
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-478-0008
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6001 EXECUTIVE BOULEVARD
-----------------------------------------------------
City | BETHESDA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20892-9663
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-478-0008
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number | 0810005485
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------