Provider Demographics
NPI:1912315342
Name:THEODORE, KRISTY (LPC)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:
Last Name:THEODORE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 S WEST ST STE 740
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-2824
Mailing Address - Country:US
Mailing Address - Phone:571-403-1283
Mailing Address - Fax:
Practice Address - Street 1:4551 STRUTFIELD LN
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22311-4967
Practice Address - Country:US
Practice Address - Phone:571-403-1283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-29
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701005491101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional