Provider Demographics
NPI:1225877020
Name:PROFFITT, KATY B (LCSW)
Entity type:Individual
Prefix:
First Name:KATY
Middle Name:B
Last Name:PROFFITT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2510 WISTAR ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23294-3512
Mailing Address - Country:US
Mailing Address - Phone:804-386-8650
Mailing Address - Fax:
Practice Address - Street 1:12020 SUNRISE VALLEY DR STE 100
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191-3429
Practice Address - Country:US
Practice Address - Phone:646-941-7645
Practice Address - Fax:929-596-7897
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-21
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040168161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical