=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457523318
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MONIQUE JEANNE DEELY LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2008
-----------------------------------------------------
Last Update Date | 03/30/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 634 PUTNAM PL
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22302-4018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-409-5249
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 625 SLATERS LN STE 103
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22314-1176
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-800-9909
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 0904009194
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | CSW003910
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------