Provider Demographics
NPI:1477661130
Name:DIVINCENZO, MARGARET MARY (MS)
Entity Type:Individual
Prefix:MS
First Name:MARGARET
Middle Name:MARY
Last Name:DIVINCENZO
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MS
Other - First Name:PEGGY
Other - Middle Name:MARY
Other - Last Name:DIVINCENZO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS
Mailing Address - Street 1:13890 BRADDOCK RD
Mailing Address - Street 2:SUITE 312
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20121-2435
Mailing Address - Country:US
Mailing Address - Phone:703-502-9112
Mailing Address - Fax:703-815-5663
Practice Address - Street 1:13890 BRADDOCK RD
Practice Address - Street 2:SUITE 312
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20121-2435
Practice Address - Country:US
Practice Address - Phone:703-502-9112
Practice Address - Fax:703-815-5663
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701001917101YM0800X
VA0717000895106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist