Provider Demographics
NPI:1245418763
Name:IRICK, MACON LOSHAWN (LCSW)
Entity Type:Individual
Prefix:
First Name:MACON
Middle Name:LOSHAWN
Last Name:IRICK
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 1:5980 9TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT BELVOIR
Mailing Address - State:VA
Mailing Address - Zip Code:22060-5509
Mailing Address - Country:US
Mailing Address - Phone:706-825-2059
Mailing Address - Fax:
Practice Address - Street 1:5980 9TH ST BLDG 1259
Practice Address - Street 2:
Practice Address - City:FORT BELVOIR
Practice Address - State:VA
Practice Address - Zip Code:22060-5509
Practice Address - Country:US
Practice Address - Phone:571-231-1210
Practice Address - Fax:571-231-6808
Is Sole Proprietor?:No
Enumeration Date:2008-02-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8523104100000X
GACSW0040861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker