Healthcare Provider Details

I. General information

NPI: 1801060355
Provider Name (Legal Business Name): WAITKUS & ASSOCIATES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2008
Last Update Date: 04/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3606 BOULEVARD SUITE B
COLONIAL HEIGHTS VA
23834-1341
US

IV. Provider business mailing address

3606 BOULEVARD SUITE B
COLONIAL HEIGHTS VA
23834-1341
US

V. Phone/Fax

Practice location:
  • Phone: 804-526-9885
  • Fax: 804-526-9884
Mailing address:
  • Phone: 804-526-9885
  • Fax: 804-526-9884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701002551
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0717000861
License Number StateVA

VIII. Authorized Official

Name: PAMELA ANN WAITKUS
Title or Position: DIRECTOR
Credential: ED.,S., LPC, LMFT
Phone: 804-526-9885