Provider Demographics
NPI:1780196212
Name:DOLAN, DAMARIS LIDIA (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:DAMARIS
Middle Name:LIDIA
Last Name:DOLAN
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2106 GALLOWS RD STE G
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3961
Mailing Address - Country:US
Mailing Address - Phone:703-957-9256
Mailing Address - Fax:
Practice Address - Street 1:2106 GALLOWS RD UNIT E
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-3961
Practice Address - Country:US
Practice Address - Phone:571-766-8455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-24
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3047235Z00000X
MD08430235Z00000X
VA2202008797235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist