Provider Demographics
NPI:1174537393
Name:MCINTOSH, SANDRA ELIZABETH ANN (LPC/RPTS/LMFT)
Entity type:Individual
Prefix:MS
First Name:SANDRA ELIZABETH
Middle Name:ANN
Last Name:MCINTOSH
Suffix:
Gender:F
Credentials:LPC/RPTS/LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1568
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20122-8568
Mailing Address - Country:US
Mailing Address - Phone:703-943-7481
Mailing Address - Fax:703-815-9057
Practice Address - Street 1:14801 RYDELL RD APT 103
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20121-4471
Practice Address - Country:US
Practice Address - Phone:703-815-9057
Practice Address - Fax:703-815-9057
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0717001317106H00000X
VA0701003105101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010214793Medicaid