Provider Demographics
NPI:1063018992
Name:LIPPOLD, JAMES ROBERT (LCSW-0904012388)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:ROBERT
Last Name:LIPPOLD
Suffix:
Gender:M
Credentials:LCSW-0904012388
Other - Prefix:
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Mailing Address - Street 1:169 EAST STREET, NE
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22180
Mailing Address - Country:US
Mailing Address - Phone:703-919-1668
Mailing Address - Fax:703-255-6171
Practice Address - Street 1:115 BEULAH ROAD, NE
Practice Address - Street 2:SUITE 200-B
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180
Practice Address - Country:US
Practice Address - Phone:703-255-7012
Practice Address - Fax:703-255-6171
Is Sole Proprietor?:No
Enumeration Date:2020-12-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904123881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0904012388OtherLICENSED CLINICAL SOCIAL WORKER (LCSW)