Provider Demographics
NPI:1265996979
Name:ROTHBERG, SHIRA ANNE (LCSW)
Entity type:Individual
Prefix:
First Name:SHIRA
Middle Name:ANNE
Last Name:ROTHBERG
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 1:4813B EISENHOWER AVE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-4832
Mailing Address - Country:US
Mailing Address - Phone:571-402-2541
Mailing Address - Fax:
Practice Address - Street 1:4813B EISENHOWER AVE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-4832
Practice Address - Country:US
Practice Address - Phone:571-402-2541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-27
Last Update Date:2019-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040108441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical