Provider Demographics
NPI:1386983393
Name:INNIS-THOMPSON, MIRTA ELVIRE (LCSW-C,LICSW, DSW)
Entity type:Individual
Prefix:
First Name:MIRTA
Middle Name:ELVIRE
Last Name:INNIS-THOMPSON
Suffix:
Gender:F
Credentials:LCSW-C,LICSW, DSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12529 GREY FOX LN
Mailing Address - Street 2:
Mailing Address - City:POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20854-1903
Mailing Address - Country:US
Mailing Address - Phone:202-763-9178
Mailing Address - Fax:240-403-7582
Practice Address - Street 1:11140 ROCKVILLE PIKE STE 480-E
Practice Address - Street 2:
Practice Address - City:NORTH BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20852-3106
Practice Address - Country:US
Practice Address - Phone:202-763-9178
Practice Address - Fax:240-403-7629
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-11
Last Update Date:2025-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC2000019331041C0700X
MD281981041C0700X
CA1019061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical