Provider Demographics
NPI:1053019901
Name:ICKES, ANNA VLADIMIROVNA (LPC)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:VLADIMIROVNA
Last Name:ICKES
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8310 MIDLOTHIAN TPKE
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23235-5163
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8310 MIDLOTHIAN TPKE
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23235-5163
Practice Address - Country:US
Practice Address - Phone:804-503-9975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-20
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701012213101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional