Provider Demographics
NPI:1558784520
Name:GOERDT, MIKI NISHIDA
Entity Type:Individual
Prefix:
First Name:MIKI
Middle Name:NISHIDA
Last Name:GOERDT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2916 LAWRENCE DR
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22042-1405
Mailing Address - Country:US
Mailing Address - Phone:703-829-6350
Mailing Address - Fax:
Practice Address - Street 1:2916 LAWRENCE DR
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22042-1405
Practice Address - Country:US
Practice Address - Phone:703-829-6350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-28
Last Update Date:2020-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040070891041C0700X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0904007089OtherVA SOCIAL WORK LICENES