Provider Demographics
NPI:1871355610
Name:STREET, TAIVIA K (LMSW)
Entity type:Individual
Prefix:
First Name:TAIVIA
Middle Name:K
Last Name:STREET
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 OLD COURTHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23236-1411
Mailing Address - Country:US
Mailing Address - Phone:804-317-2526
Mailing Address - Fax:
Practice Address - Street 1:3300 OLD COURTHOUSE RD
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23236-1411
Practice Address - Country:US
Practice Address - Phone:804-317-2526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-26
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0903002167171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator