Provider Demographics
NPI:1932119393
Name:SOURS, RENEE (LCSW)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:SOURS
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 1:3 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:LURAY
Mailing Address - State:VA
Mailing Address - Zip Code:22835-1725
Mailing Address - Country:US
Mailing Address - Phone:240-477-2656
Mailing Address - Fax:
Practice Address - Street 1:441 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:VA
Practice Address - Zip Code:22664-1801
Practice Address - Country:US
Practice Address - Phone:540-459-4946
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD130411041C0700X
VA09040081271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD008347000Medicaid