Provider Demographics
NPI:1104907104
Name:DANIEL, DEBORAH LYNN (LCSW)
Entity type:Individual
Prefix:MRS
First Name:DEBORAH
Middle Name:LYNN
Last Name:DANIEL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:DEBORAH
Other - Middle Name:LYNN
Other - Last Name:DANIEL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 555
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-0555
Mailing Address - Country:US
Mailing Address - Phone:804-717-1111
Mailing Address - Fax:804-717-1185
Practice Address - Street 1:1133 JEFFERSON GREEN CIR
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-4300
Practice Address - Country:US
Practice Address - Phone:804-717-1111
Practice Address - Fax:804-717-1185
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2011-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2044101YM0800X
VA09040020441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1104907104Medicaid
VA190000809OtherMEDICARE