Provider Demographics
NPI:1215019559
Name:CHELPON, CONSTANTINE THEODORE (LCSW)
Entity Type:Individual
Prefix:MR
First Name:CONSTANTINE
Middle Name:THEODORE
Last Name:CHELPON
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 1:5610 SANDY LEWIS DR STE A
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22032-4045
Mailing Address - Country:US
Mailing Address - Phone:703-425-8269
Mailing Address - Fax:
Practice Address - Street 1:5610 SANDY LEWIS DR STE A
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22032-4045
Practice Address - Country:US
Practice Address - Phone:703-425-8269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040047721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC741OtherCARE FIRST
VA1775906Medicaid
VA630209OtherANTHEM
VA514469Medicare ID - Type Unspecified