Provider Demographics
NPI:1497185805
Name:PINKERTON, TISA MCKENNA (LCSW)
Entity type:Individual
Prefix:
First Name:TISA
Middle Name:MCKENNA
Last Name:PINKERTON
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 1:11204 WAPLES MILL RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-6036
Mailing Address - Country:US
Mailing Address - Phone:703-218-8500
Mailing Address - Fax:
Practice Address - Street 1:11204 WAPLES MILL RD
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030
Practice Address - Country:US
Practice Address - Phone:703-218-8500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-21
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC500791201041C0700X
VA09040090001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty