Provider Demographics
NPI:1306869995
Name:ANDERSON, MARK ROBERT (LCSW)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:ROBERT
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 N WASHINGTON ST STE 104
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22046-3410
Mailing Address - Country:US
Mailing Address - Phone:703-405-4209
Mailing Address - Fax:703-533-9433
Practice Address - Street 1:405 N WASHINGTON ST STE 104
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22046-3410
Practice Address - Country:US
Practice Address - Phone:703-405-4209
Practice Address - Fax:703-533-9433
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040027731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA54-1300393OtherFEIN