Provider Demographics
NPI:1407395791
Name:MALAWISTA, KERRY LEDDY (MSW, PHD)
Entity Type:Individual
Prefix:DR
First Name:KERRY
Middle Name:LEDDY
Last Name:MALAWISTA
Suffix:
Gender:F
Credentials:MSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6842 ELM ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-3891
Mailing Address - Country:US
Mailing Address - Phone:703-734-1100
Mailing Address - Fax:
Practice Address - Street 1:6842 ELM ST
Practice Address - Street 2:SUITE 104
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-3891
Practice Address - Country:US
Practice Address - Phone:703-734-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-20
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040012791041C0700X
MD52591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical