MEDICARE: CHRISTINA MADSEN FISHBACK 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	104100000X	Social Worker	0903002595	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0903002595	OTHER	VA	COMMONWEALTH OF VIRGINIA DEPARTMENT OF HEALTH PROFESSIONS

General Provider Information

NPI Number	:	1821576547
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINA MADSEN FISHBACK LCSW

Provider Business Mailing Address
First Line	:	3388 WILTON CREST CT
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22310-2354
Country	:	US
Telephone Number	:	831-236-5801
Fax Number	:	703-842-8135

Provider Business Practice Location Address
First Line	:	218 N LEE ST STE 201
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22314-2631
Country	:	US
Telephone Number	:	831-236-5801
Fax Number	:	703-842-8135

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

Provider Enumeration Date	:	08/03/2018
Last Update Date	:	06/09/2021

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