Provider Demographics
NPI:1861599904
Name:BOOMER, ELAINE P (LCSW)
Entity type:Individual
Prefix:MS
First Name:ELAINE
Middle Name:P
Last Name:BOOMER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:ELAINE
Other - Middle Name:P
Other - Last Name:BOOMER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:501 CHURCH ST NE STE 206
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22180-4734
Mailing Address - Country:US
Mailing Address - Phone:703-255-2208
Mailing Address - Fax:703-255-2482
Practice Address - Street 1:501 CHURCH ST NE STE 206
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180-4734
Practice Address - Country:US
Practice Address - Phone:703-255-2208
Practice Address - Fax:703-255-2482
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040038381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical