Provider Demographics
NPI:1689823700
Name:PHALEN, AUDRA VICTORIA (LCSW, LICSW)
Entity Type:Individual
Prefix:MRS
First Name:AUDRA
Middle Name:VICTORIA
Last Name:PHALEN
Suffix:
Gender:F
Credentials:LCSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 WOODBURN RD
Mailing Address - Street 2:
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003-1202
Mailing Address - Country:US
Mailing Address - Phone:703-573-0523
Mailing Address - Fax:703-280-9518
Practice Address - Street 1:3340 WOODBURN RD
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-1202
Practice Address - Country:US
Practice Address - Phone:703-573-0523
Practice Address - Fax:703-280-9518
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-12
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040068991041C0700X
DCLG500785511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical