Provider Demographics
NPI:1407161565
Name:SEDJAT, LISA B (LCSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:B
Last Name:SEDJAT
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 1:2108 THOROUGHGOOD RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-4015
Mailing Address - Country:US
Mailing Address - Phone:757-416-5325
Mailing Address - Fax:757-416-5326
Practice Address - Street 1:2108 THOROUGHGOOD RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-4015
Practice Address - Country:US
Practice Address - Phone:757-416-5325
Practice Address - Fax:757-416-5326
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-13
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040027711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1902839277Medicaid
VA0152882137Medicaid
VA0102994115Medicaid
VA0101569637Medicaid