Provider Demographics
NPI:1720318231
Name:RYAN KIDD, TRACY JOAN (LCSW)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:JOAN
Last Name:RYAN KIDD
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 1:410 MAPLE AVE W STE 7
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22180-4224
Mailing Address - Country:US
Mailing Address - Phone:703-281-9313
Mailing Address - Fax:703-281-9769
Practice Address - Street 1:410 MAPLE AVE W STE 7
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180-4224
Practice Address - Country:US
Practice Address - Phone:703-281-9313
Practice Address - Fax:703-281-9769
Is Sole Proprietor?:No
Enumeration Date:2010-01-05
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040018551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical