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General NPI Number Information
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NPI Number | 1174150429
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Entity Type | Individual
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Provider Name | KATHERINE MARIE ILLGEN LCSW, CCTP
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Gender | Female
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Dates
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Enumeration Date | 03/26/2020
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Last Update Date | 09/15/2022
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Provider Practice Location Address
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Address Line | 6515 GEORGE WASHINGTON MEM HWY
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City | YORKTOWN
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State | VA
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Zip | 23692-2182
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Country | US
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Telephone | 757-877-9140
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Fax |
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Provider Business Mailing Address
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Address Line | 600 MEDICAL DR
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City | HAMPTON
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State | VA
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Zip | 23666-1769
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Country | US
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Telephone | 757-788-0649
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 090411313
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License Number State | VA
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