Provider Demographics
NPI:1720450943
Name:STREET, CARL (LPC)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:
Last Name:STREET
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 1:14488 SHARPSHINNED DR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20155-5837
Mailing Address - Country:US
Mailing Address - Phone:703-753-7229
Mailing Address - Fax:
Practice Address - Street 1:11835 HAZEL CIRCLE DR
Practice Address - Street 2:
Practice Address - City:BRISTOW
Practice Address - State:VA
Practice Address - Zip Code:20136-2180
Practice Address - Country:US
Practice Address - Phone:703-636-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-27
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701005656101Y00000X
VA0718000249101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)