Provider Demographics
NPI:1659003622
Name:CHARLES, DANIETTA (LPC)
Entity Type:Individual
Prefix:
First Name:DANIETTA
Middle Name:
Last Name:CHARLES
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8209 PERIDOT DR UNIT 306
Mailing Address - Street 2:
Mailing Address - City:TYSONS CORNER
Mailing Address - State:VA
Mailing Address - Zip Code:22102-3968
Mailing Address - Country:US
Mailing Address - Phone:315-399-6318
Mailing Address - Fax:
Practice Address - Street 1:9677 MAIN ST
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-3763
Practice Address - Country:US
Practice Address - Phone:301-767-1733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-28
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701011580101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty