Provider Demographics
NPI:1528499407
Name:VANDEVANTER, MARY (LCSW)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:VANDEVANTER
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 1:6505 OAKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22041-1109
Mailing Address - Country:US
Mailing Address - Phone:703-370-6525
Mailing Address - Fax:
Practice Address - Street 1:6001 TOWER CT
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-3201
Practice Address - Country:US
Practice Address - Phone:703-370-6525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-03
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040021041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical