Provider Demographics
NPI:1093805236
Name:JURICH, MADELINE PETRIZZI (LCSW)
Entity type:Individual
Prefix:MRS
First Name:MADELINE
Middle Name:PETRIZZI
Last Name:JURICH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 TOWN CENTER DR
Mailing Address - Street 2:STE 411
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190
Mailing Address - Country:US
Mailing Address - Phone:703-437-3236
Mailing Address - Fax:703-435-7422
Practice Address - Street 1:1800 TOWN CENTER DR
Practice Address - Street 2:STE 411
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190
Practice Address - Country:US
Practice Address - Phone:703-437-3236
Practice Address - Fax:703-435-7422
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904002351104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA101380OtherANTHEM BCBS
127232OtherVALUE OPTIONS
VA101380OtherANTHEM BCBS