Provider Demographics
NPI:1548585334
Name:ETKIND, SUSAN A (PSYD, PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:A
Last Name:ETKIND
Suffix:
Gender:F
Credentials:PSYD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10332 MAIN ST # 282
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-2410
Mailing Address - Country:US
Mailing Address - Phone:703-673-7113
Mailing Address - Fax:
Practice Address - Street 1:4339 ANDES DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-5360
Practice Address - Country:US
Practice Address - Phone:301-312-1003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-05
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
VA0810004926103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100000380 0039 CCC'SMedicaid