Provider Demographics
NPI:1174150429
Name:ILLGEN, KATHERINE MARIE (LCSW, CCTP)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:MARIE
Last Name:ILLGEN
Suffix:
Gender:F
Credentials:LCSW, CCTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-1769
Mailing Address - Country:US
Mailing Address - Phone:757-788-0649
Mailing Address - Fax:
Practice Address - Street 1:6515 GEORGE WASHINGTON MEM HWY
Practice Address - Street 2:
Practice Address - City:YORKTOWN
Practice Address - State:VA
Practice Address - Zip Code:23692-2182
Practice Address - Country:US
Practice Address - Phone:757-877-9140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-26
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904113131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical