Provider Demographics
NPI:1407173248
Name:LIFESPAN COUNSELING SERVICES, LLC
Entity Type:Organization
Organization Name:LIFESPAN COUNSELING SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORKER
Authorized Official - Prefix:MS
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:C
Authorized Official - Last Name:NICHOLSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:703-490-9681
Mailing Address - Street 1:5104 COLERIDGE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22032-2420
Mailing Address - Country:US
Mailing Address - Phone:703-965-8712
Mailing Address - Fax:
Practice Address - Street 1:8500 EXECUTIVE PARK AVE STE 204
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-2253
Practice Address - Country:US
Practice Address - Phone:703-876-8480
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-03
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040068011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA12093630OtherCAQH