Provider Demographics
NPI:1316169642
Name:PHOTIADIS, THERESE P (LCSW)
Entity type:Individual
Prefix:MS
First Name:THERESE
Middle Name:P
Last Name:PHOTIADIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1485 CHAIN BRIDGE RD
Mailing Address - Street 2:204
Mailing Address - City:MCLEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-4501
Mailing Address - Country:US
Mailing Address - Phone:703-734-1477
Mailing Address - Fax:703-734-6333
Practice Address - Street 1:1485 CHAIN BRIDGE RD
Practice Address - Street 2:204
Practice Address - City:MCLEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-4501
Practice Address - Country:US
Practice Address - Phone:703-734-1477
Practice Address - Fax:703-734-6333
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040022751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical