Provider Demographics
NPI:1003860834
Name:DERVIN, KATHERINE (LCSW)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:DERVIN
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 1:12000 KENNEDY LN
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22407-6016
Mailing Address - Country:US
Mailing Address - Phone:540-548-2063
Mailing Address - Fax:540-548-2962
Practice Address - Street 1:12000 KENNEDY LN
Practice Address - Street 2:SUITE 100
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407-6016
Practice Address - Country:US
Practice Address - Phone:540-548-2063
Practice Address - Fax:540-548-2962
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040000161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical