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General NPI Number Information
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NPI Number | 1912315342
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Entity Type | Individual
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Provider Name | KRISTY THEODORE LPC
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Gender | Female
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Dates
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Enumeration Date | 07/29/2014
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Last Update Date | 09/16/2021
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Provider Practice Location Address
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Address Line | 4551 STRUTFIELD LN
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City | ALEXANDRIA
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State | VA
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Zip | 22311-4967
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Country | US
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Telephone | 571-403-1283
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Fax |
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Provider Business Mailing Address
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Address Line | 107 S WEST ST STE 740
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City | ALEXANDRIA
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State | VA
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Zip | 22314-2824
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Country | US
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Telephone | 571-403-1283
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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 | 0701005491
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License Number State | VA
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