Provider Demographics
NPI:1124091046
Name:JOELSSON, MIA RENEE (LCSW-C)
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:RENEE
Last Name:JOELSSON
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:MIA
Other - Middle Name:RENEE
Other - Last Name:PETERITAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:205 RIDGEPOINT PL
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20878-5703
Mailing Address - Country:US
Mailing Address - Phone:484-432-3213
Mailing Address - Fax:866-613-8972
Practice Address - Street 1:849 QUINCE ORCHARD BLVD STE D
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20878-1604
Practice Address - Country:US
Practice Address - Phone:240-454-3002
Practice Address - Fax:866-613-8972
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-10
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0147491041C0700X
MD178531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical