Provider Demographics
NPI:1134112402
Name:BERDEQUEZ, LOREN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:LOREN
Middle Name:
Last Name:BERDEQUEZ
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8680 HOSPITAL WAY
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-4287
Mailing Address - Country:US
Mailing Address - Phone:703-369-8055
Mailing Address - Fax:703-369-8565
Practice Address - Street 1:8680 HOSPITAL WAY
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-4287
Practice Address - Country:US
Practice Address - Phone:703-369-8055
Practice Address - Fax:703-369-8565
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040052511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAN/AMedicaid
N/AMedicare UPIN
N/AMedicare ID - Type Unspecified