Provider Demographics
NPI:1407936313
Name:MACDONALD, JOELLE ANTONIA (LCSW)
Entity Type:Individual
Prefix:
First Name:JOELLE
Middle Name:ANTONIA
Last Name:MACDONALD
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 1:3502 LAUNCELOT WAY
Mailing Address - Street 2:
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003-1357
Mailing Address - Country:US
Mailing Address - Phone:703-560-8129
Mailing Address - Fax:
Practice Address - Street 1:9870B MAIN ST
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-3908
Practice Address - Country:US
Practice Address - Phone:703-869-8464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040025921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA193715OtherANTHEM BLUE CROSS
VAM565-0002OtherCARE FIRST BLUE CROSS BLU
VA019367P39Medicare ID - Type Unspecified