Provider Demographics
NPI:1972039055
Name:DERDERIAN, KRISTINA BLOUGH (LPC)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:BLOUGH
Last Name:DERDERIAN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 N BOULEVARD APT 7
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23220-4028
Mailing Address - Country:US
Mailing Address - Phone:804-338-1662
Mailing Address - Fax:
Practice Address - Street 1:317 N BOULEVARD APT 7
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23220-4028
Practice Address - Country:US
Practice Address - Phone:804-338-1662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-10
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701006384101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional