Provider Demographics
NPI:1912302308
Name:WANNON, NATALIA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:NATALIA
Middle Name:
Last Name:WANNON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1408 N FILLMORE ST STE 2
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22201-3819
Mailing Address - Country:US
Mailing Address - Phone:301-325-5130
Mailing Address - Fax:
Practice Address - Street 1:1408 N FILLMORE ST STE 2
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22201-3819
Practice Address - Country:US
Practice Address - Phone:301-325-5130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-28
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA1912302308103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program