Provider Demographics
NPI:1558082958
Name:BASSO, COLLEEN GRAYDON (LCSW)
Entity type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:GRAYDON
Last Name:BASSO
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 1:815B AMBROSE LN
Mailing Address - Street 2:
Mailing Address - City:MANASSAS PARK
Mailing Address - State:VA
Mailing Address - Zip Code:20111-2706
Mailing Address - Country:US
Mailing Address - Phone:703-517-3260
Mailing Address - Fax:
Practice Address - Street 1:815B AMBROSE LN
Practice Address - Street 2:
Practice Address - City:MANASSAS PARK
Practice Address - State:VA
Practice Address - Zip Code:20111-2706
Practice Address - Country:US
Practice Address - Phone:703-517-3260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-06
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040138501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical