Provider Demographics
NPI:1871837781
Name:BARTAKKE, NAOMI PHYLLIS (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:NAOMI
Middle Name:PHYLLIS
Last Name:BARTAKKE
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 1:11250 ROGER BACON DR
Mailing Address - Street 2:SUITE 6
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-5219
Mailing Address - Country:US
Mailing Address - Phone:571-250-6978
Mailing Address - Fax:877-334-0608
Practice Address - Street 1:11250 ROGER BACON DR
Practice Address - Street 2:SUITE 6
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5219
Practice Address - Country:US
Practice Address - Phone:571-250-6978
Practice Address - Fax:877-334-0608
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040019221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical