Provider Demographics
NPI:1043898935
Name:OLD TOWN PSYCHOTHERAPY
Entity Type:Organization
Organization Name:OLD TOWN PSYCHOTHERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:MADSEN
Authorized Official - Last Name:FISHBACK
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:831-236-5801
Mailing Address - Street 1:218 N LEE ST STE 201
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-2631
Mailing Address - Country:US
Mailing Address - Phone:831-236-5801
Mailing Address - Fax:703-842-8135
Practice Address - Street 1:218 N LEE ST STE 201
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-2631
Practice Address - Country:US
Practice Address - Phone:831-236-5801
Practice Address - Fax:703-842-8135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-31
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health