Provider Demographics
NPI:1467834135
Name:NIELSEN, VIRGINIA ROXANN
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:ROXANN
Last Name:NIELSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VIRGINIA
Other - Middle Name:ROXANN
Other - Last Name:FORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 NICHOLAS DR LOT E21
Mailing Address - Street 2:
Mailing Address - City:CLIFTON FORGE
Mailing Address - State:VA
Mailing Address - Zip Code:24422-1919
Mailing Address - Country:US
Mailing Address - Phone:571-268-6751
Mailing Address - Fax:833-788-0610
Practice Address - Street 1:100 NICHOLAS DR LOT E21
Practice Address - Street 2:
Practice Address - City:CLIFTON FORGE
Practice Address - State:VA
Practice Address - Zip Code:24422-1919
Practice Address - Country:US
Practice Address - Phone:571-268-6751
Practice Address - Fax:833-788-0610
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-18
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60672422101YM0800X
101Y00000X, 101YM0800X
VA07010109000101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA214041Medicaid