Provider Demographics
NPI:1841674421
Name:BLACK, ANNA KATHERINE (PHD)
Entity type:Individual
Prefix:DR
First Name:ANNA KATHERINE
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:PHD
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 154
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX STATION
Mailing Address - State:VA
Mailing Address - Zip Code:22039-0154
Mailing Address - Country:US
Mailing Address - Phone:703-910-2577
Mailing Address - Fax:
Practice Address - Street 1:5244 LYNGATE CT STE 200
Practice Address - Street 2:
Practice Address - City:BURKE
Practice Address - State:VA
Practice Address - Zip Code:22015-1631
Practice Address - Country:US
Practice Address - Phone:703-910-2577
Practice Address - Fax:703-661-9463
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-14
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS60-1047103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical