Provider Demographics
NPI:1467022483
Name:FITZ-RANDOLPH, HEATHER (RIC)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:FITZ-RANDOLPH
Suffix:
Gender:F
Credentials:RIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2226 MOHEGAN DR APT 102
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22043-2534
Mailing Address - Country:US
Mailing Address - Phone:703-201-7293
Mailing Address - Fax:
Practice Address - Street 1:306 GARRISONVILLE RD STE 201
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22554-1575
Practice Address - Country:US
Practice Address - Phone:540-602-7615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-30
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704013225101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor