MEDICARE: MS. MARY MISCHTSCHUK LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	10740	MD
2	1041C0700X	Clinical Social Worker	LC50081376	DC
3	1041C0700X	Clinical Social Worker	0904005510	VA

General Provider Information

NPI Number	:	1043293012
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY MISCHTSCHUK LCSW

Provider Business Mailing Address
First Line	:	4300 KING ST
Second Line	:	SUITE 130
City	:	ALEXANDRIA
State	:	VA
Zip	:	22302-1503
Country	:	US
Telephone Number	:	703-879-5144
Fax Number	:	703-879-5860

Provider Business Practice Location Address
First Line	:	12721 DARBY BROOK CT STE 102
Second Line	:
City	:	WOODBRIDGE
State	:	VA
Zip	:	22192-2408
Country	:	US
Telephone Number	:	703-879-5144
Fax Number	:	703-879-5860

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/23/2005
Last Update Date	:	10/07/2017

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