Provider Demographics
NPI:1316364938
Name:MADISON, OCTAVIA DIANNE (EDD, LPC, LMFT)
Entity type:Individual
Prefix:MS
First Name:OCTAVIA
Middle Name:DIANNE
Last Name:MADISON
Suffix:
Gender:F
Credentials:EDD, LPC, LMFT
Other - Prefix:MRS
Other - First Name:OCTAVIA
Other - Middle Name:DIANNE
Other - Last Name:MADISON-COLMORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:EDD, LPC, LMFT
Mailing Address - Street 1:2100 WASHINGTON BLVD
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22204-5703
Mailing Address - Country:US
Mailing Address - Phone:703-228-1600
Mailing Address - Fax:703-228-1117
Practice Address - Street 1:2100 WASHINGTON BLVD
Practice Address - Street 2:4TH FLOOR
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22204-5703
Practice Address - Country:US
Practice Address - Phone:703-228-1600
Practice Address - Fax:703-228-1117
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-20
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
VA0701001856101YP2500X
VA0717000584106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist