Provider Demographics
NPI:1891529814
Name:WIEDERHOLT, ELIZABETH NICOLE (LPC)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:NICOLE
Last Name:WIEDERHOLT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6400 GROVEDALE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22310-2504
Mailing Address - Country:US
Mailing Address - Phone:571-356-8360
Mailing Address - Fax:
Practice Address - Street 1:6400 GROVEDALE DR STE 200
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22310-2504
Practice Address - Country:US
Practice Address - Phone:571-356-8360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-30
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701013940101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional