Provider Demographics
NPI:1205456126
Name:MOUSSA, MARY (LPC, CSAC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MOUSSA
Suffix:
Gender:F
Credentials:LPC, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10560 MAIN ST STE 415
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-7174
Mailing Address - Country:US
Mailing Address - Phone:571-318-6710
Mailing Address - Fax:
Practice Address - Street 1:10560 MAIN ST STE 415
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-7174
Practice Address - Country:US
Practice Address - Phone:571-318-6710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-21
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0710103429101YA0400X
VA0701009845101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)