Provider Demographics
NPI:1255809240
Name:LAM, MICHELLE ANN ENSRUD (LCSW)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:ANN ENSRUD
Last Name:LAM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:ANN
Other - Last Name:LAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3305 KINFOLK CT
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20171-4011
Mailing Address - Country:US
Mailing Address - Phone:540-220-3002
Mailing Address - Fax:
Practice Address - Street 1:4460 BROOKFIELD CORPORATE DR STE H
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-1671
Practice Address - Country:US
Practice Address - Phone:571-933-8151
Practice Address - Fax:571-933-8438
Is Sole Proprietor?:No
Enumeration Date:2018-11-07
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040107701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical