Provider Demographics
NPI:1821890203
Name:LABELLE, TRISTAN MARK (LCSW)
Entity type:Individual
Prefix:MR
First Name:TRISTAN
Middle Name:MARK
Last Name:LABELLE
Suffix:
Gender:
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 FRANTZ ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-4544
Mailing Address - Country:US
Mailing Address - Phone:352-346-9036
Mailing Address - Fax:
Practice Address - Street 1:1970 ROANOKE BLVD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-6404
Practice Address - Country:US
Practice Address - Phone:540-982-2463
Practice Address - Fax:540-353-8786
Is Sole Proprietor?:No
Enumeration Date:2025-03-26
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040174001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical