Provider Demographics
NPI:1407206980
Name:MADSEN, KIRSTEN
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:
Last Name:MADSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6007 MAYFAIR LN
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22310-1111
Mailing Address - Country:US
Mailing Address - Phone:202-758-5356
Mailing Address - Fax:
Practice Address - Street 1:6007 MAYFAIR LN
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22310-1111
Practice Address - Country:US
Practice Address - Phone:202-758-5356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-15
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPRC14591101YP2500X
VA0701007743101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional