Provider Demographics
NPI:1558380758
Name:O'SHEA, J. MARK (LCSW)
Entity Type:Individual
Prefix:
First Name:J.
Middle Name:MARK
Last Name:O'SHEA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4906 MILLRIDGE PKWY E
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-4828
Mailing Address - Country:US
Mailing Address - Phone:804-744-5611
Mailing Address - Fax:804-528-4937
Practice Address - Street 1:4906 MILLRIDGE PKWY E
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-4828
Practice Address - Country:US
Practice Address - Phone:804-744-5611
Practice Address - Fax:804-528-4937
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040016381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010026997Medicaid
VA142616OtherANTHEM BLUE CROSS
VA142616OtherANTHEM BLUE CROSS