Provider Demographics
NPI:1821576547
Name:FISHBACK, CHRISTINA MADSEN (LCSW)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:MADSEN
Last Name:FISHBACK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3388 WILTON CREST CT
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22310-2354
Mailing Address - Country:US
Mailing Address - Phone:831-236-5801
Mailing Address - Fax:703-842-8135
Practice Address - Street 1:218 N LEE ST STE 201
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-2631
Practice Address - Country:US
Practice Address - Phone:831-236-5801
Practice Address - Fax:703-842-8135
Is Sole Proprietor?:No
Enumeration Date:2018-08-03
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0903002595104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0903002595OtherCOMMONWEALTH OF VIRGINIA DEPARTMENT OF HEALTH PROFESSIONS