Provider Demographics
NPI:1689197790
Name:ALEXANDRIA ART THERAPY, LLC
Entity Type:Organization
Organization Name:ALEXANDRIA ART THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ADELE
Authorized Official - Middle Name:
Authorized Official - Last Name:STUCKEY
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC, ATR-BC
Authorized Official - Phone:703-596-9557
Mailing Address - Street 1:1008 PENDLETON ST STE 1A
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-2182
Mailing Address - Country:US
Mailing Address - Phone:703-596-9557
Mailing Address - Fax:
Practice Address - Street 1:1008 PENDLETON ST STE 1A
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-2182
Practice Address - Country:US
Practice Address - Phone:703-596-9557
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-20
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701007203101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty