Provider Demographics
NPI:1710741426
Name:BETYAK-EISLER, MARY JO (LMHC, LPC, CSAC)
Entity Type:Individual
Prefix:
First Name:MARY JO
Middle Name:
Last Name:BETYAK-EISLER
Suffix:
Gender:F
Credentials:LMHC, LPC, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 WAGONEERS LN
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554-8521
Mailing Address - Country:US
Mailing Address - Phone:619-507-7254
Mailing Address - Fax:
Practice Address - Street 1:77 WAGONEERS LN
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22554-8521
Practice Address - Country:US
Practice Address - Phone:619-507-7254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-13
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0710102795101YA0400X
NY004087-01101YM0800X
VA0701005517101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health