Provider Demographics
NPI:1396519161
Name:DATOFF, VIVIAN PATRICIA
Entity type:Individual
Prefix:
First Name:VIVIAN
Middle Name:PATRICIA
Last Name:DATOFF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2022 SPRING BRANCH DR
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22181-2973
Mailing Address - Country:US
Mailing Address - Phone:703-579-7899
Mailing Address - Fax:
Practice Address - Street 1:17 WARREN RD STE 25A
Practice Address - Street 2:
Practice Address - City:PIKESVILLE
Practice Address - State:MD
Practice Address - Zip Code:21208-5003
Practice Address - Country:US
Practice Address - Phone:703-579-7899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD09332101YM0800X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health