Provider Demographics
NPI:1154494243
Name:KOUSSOGLOU, GEORGE A (LCSW)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:A
Last Name:KOUSSOGLOU
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 1:10128 HULL STREET RD
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-3300
Mailing Address - Country:US
Mailing Address - Phone:804-276-5761
Mailing Address - Fax:804-745-3626
Practice Address - Street 1:10128 HULL STREET RD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-3300
Practice Address - Country:US
Practice Address - Phone:804-276-5761
Practice Address - Fax:804-745-3626
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040060931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical