Provider Demographics
NPI:1114039476
Name:NEAL, ELLEN M (LCSW)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:M
Last Name:NEAL
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 1:297 HERNDON PKWY
Mailing Address - Street 2:SUITE 202
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-4474
Mailing Address - Country:US
Mailing Address - Phone:703-220-0107
Mailing Address - Fax:703-266-3677
Practice Address - Street 1:297 HERNDON PKWY
Practice Address - Street 2:SUITE 202
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-4474
Practice Address - Country:US
Practice Address - Phone:703-220-0107
Practice Address - Fax:703-266-3677
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2012-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040061701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA149790OtherMEDICARE PTAN
VA11567919OtherCAQH NUMBER
VA492150Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER