Provider Demographics
NPI:1093922643
Name:SAYRE, MARY MARTHA (MED, LPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MARTHA
Last Name:SAYRE
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10375 DEMOCRACY LN STE B
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-2554
Mailing Address - Country:US
Mailing Address - Phone:703-383-0673
Mailing Address - Fax:
Practice Address - Street 1:10375 DEMOCRACY LN STE B
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-2554
Practice Address - Country:US
Practice Address - Phone:703-383-0673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701003432101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health