Provider Demographics
NPI:1114156601
Name:MALDONADO, MERRIELLYN J (LCSW)
Entity Type:Individual
Prefix:
First Name:MERRIELLYN
Middle Name:J
Last Name:MALDONADO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MERRIELLYN
Other - Middle Name:J
Other - Last Name:RENNARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7969 ASHTON AVE
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20109-2885
Mailing Address - Country:US
Mailing Address - Phone:703-792-7800
Mailing Address - Fax:703-792-5699
Practice Address - Street 1:2120 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22204
Practice Address - Country:US
Practice Address - Phone:703-228-5002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-07
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040079831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004945247Medicaid