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General NPI Number Information
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NPI Number | 1619517091
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Entity Type | Individual
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Provider Name | CARISSA MONICA MARTIN LPC
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Gender | Female
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Dates
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Enumeration Date | 01/13/2020
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Last Update Date | 01/13/2020
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Provider Practice Location Address
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Address Line | 6901 S VAN DORN ST
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City | ALEXANDRIA
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State | VA
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Zip | 22315-3961
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Country | US
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Telephone | 703-313-6362
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Fax |
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Provider Business Mailing Address
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Address Line | 1219 FLORIDA AVE NE APT 4
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City | WASHINGTON
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State | DC
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Zip | 20002-7131
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Country | US
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Telephone |
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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 | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 0701008859
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License Number State |
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