Provider Demographics
NPI:1720459746
Name:RAD, MICHELLE (LCP, PSYD, MA)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:
Last Name:RAD
Suffix:
Gender:F
Credentials:LCP, PSYD, MA
Other - Prefix:DR
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:RAD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCP, PSYD, MA
Mailing Address - Street 1:43803 MICHENER DR
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-5807
Mailing Address - Country:US
Mailing Address - Phone:703-443-4924
Mailing Address - Fax:
Practice Address - Street 1:43803 MICHENER DR
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-5807
Practice Address - Country:US
Practice Address - Phone:703-443-4924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-16
Last Update Date:2018-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810005315103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0810005315OtherLICENSED CLINICAL PSYCHOLOGIST, VA BOARD OF PSYCHOLOGY