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General NPI Number Information
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NPI Number | 1255809240
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Entity Type | Individual
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Provider Name | MICHELLE ANN ENSRUD LAM LCSW
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Gender | Female
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Dates
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Enumeration Date | 11/07/2018
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Last Update Date | 01/06/2020
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Provider Practice Location Address
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Address Line | 4460 BROOKFIELD CORPORATE DR STE H
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City | CHANTILLY
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State | VA
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Zip | 20151-1671
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Country | US
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Telephone | 571-933-8151
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Fax | 571-933-8438
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Provider Business Mailing Address
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Address Line | 3305 KINFOLK CT
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City | HERNDON
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State | VA
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Zip | 20171-4011
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Country | US
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Telephone | 540-220-3002
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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 | 0904010770
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License Number State | VA
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