Provider Demographics
NPI:1457880684
Name:BROGDON, CLINTON LEE (LPC)
Entity Type:Individual
Prefix:
First Name:CLINTON
Middle Name:LEE
Last Name:BROGDON
Suffix:
Gender:M
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:PO BOX 230444
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20120-0444
Mailing Address - Country:US
Mailing Address - Phone:571-528-0805
Mailing Address - Fax:
Practice Address - Street 1:11204 WAPLES MILL RD
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-6036
Practice Address - Country:US
Practice Address - Phone:703-218-8500
Practice Address - Fax:703-359-0463
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-10
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
VA0701007411101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional