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General NPI Number Information
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NPI Number | 1477869246
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Entity Type | Individual
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Provider Name | RUTH PROVENZANO LCSW
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Gender | Female
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Dates
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Enumeration Date | 08/31/2010
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Last Update Date | 07/02/2013
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Provider Practice Location Address
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Address Line | 9924 STEEPLE RUN
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City | VIENNA
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State | VA
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Zip | 22181-3157
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Country | US
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Telephone | 703-967-5313
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Fax |
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Provider Business Mailing Address
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Address Line | 9924 STEEPLE RUN
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City | VIENNA
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State | VA
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Zip | 22181-3157
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Country | US
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Telephone | 703-967-5313
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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 | 0904008275
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License Number State | VA
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