Provider Demographics
NPI:1770009425
Name:CHRISTIAN, KATHLEEN ANN (PHD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:ANN
Last Name:CHRISTIAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12150 PURPLE SAGE CT
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20194-5621
Mailing Address - Country:US
Mailing Address - Phone:571-299-8616
Mailing Address - Fax:
Practice Address - Street 1:11250 ROGER BACON DR STE 5
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5202
Practice Address - Country:US
Practice Address - Phone:571-299-8616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-15
Last Update Date:2017-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810005019103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA08110005019OtherLICENSED CLINICAL PSYCHOLOGIST