MEDICARE: MS. RITA THERESA MAISE I 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	0904001261	VA

General Provider Information

NPI Number	:	1346340403
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. RITA THERESA MAISE I LCSW

Provider Business Mailing Address
First Line	:	10125 WOOD GREEN WAY
Second Line	:
City	:	BURKE
State	:	VA
Zip	:	22015-2714
Country	:	US
Telephone Number	:	703-503-7849
Fax Number	:

Provider Business Practice Location Address
First Line	:	13649 OFFICE PL
Second Line	:	#102
City	:	WOODBRIDGE
State	:	VA
Zip	:	22192-4215
Country	:	US
Telephone Number	:	703-670-5738
Fax Number	:	703-670-8213

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

Provider Enumeration Date	:	09/25/2006
Last Update Date	:	07/31/2009

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