Provider Demographics
NPI:1760592612
Name:GEORGE, THERESA MARIE (LPC)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:MARIE
Last Name:GEORGE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:TERRI
Other - Middle Name:
Other - Last Name:GEORGE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:102 HERITAGE WAY NE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-4544
Mailing Address - Country:US
Mailing Address - Phone:703-771-5163
Mailing Address - Fax:
Practice Address - Street 1:102 HERITAGE WAY NE
Practice Address - Street 2:SUITE 302
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-4544
Practice Address - Country:US
Practice Address - Phone:703-771-5163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701003264101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA385153OtherANTHEM
VA540948306OtherTRICARE
VA293870OtherAMERIGROUP