Individual
MIRJANA IVANISEVIC
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PHD
Contact information
Practice address
3300 GALLOWS RD, FALLS CHURCH, VA 22042-3307
(678) 697-7240
Mailing address
PO BOX 37174, BALTIMORE, MD 21297-3174
(571) 423-5699
(571) 423-5698
Taxonomy
Speciality
Code
Description
License number
State
103G00000X
Clinical Neuropsychologist
Primary
0810007786
VA
103TC0700X
Clinical Psychologist
0810007786
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0810007786
VIRGINIA DEPARTMENT OF HEALTH PROFESSIONALS
VA
Enumeration date
06/27/2022
Last updated
09/09/2022
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