Healthcare Provider Details

I. General information

NPI: 1720558075
Provider Name (Legal Business Name): DAVID RICHARD FLY PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2018
Last Update Date: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 STERNBERG AVE
FORT EUSTIS VA
23604-1527
US

IV. Provider business mailing address

732 THIMBLE SHOALS BLVD STE 203
NEWPORT NEWS VA
23606-4262
US

V. Phone/Fax

Practice location:
  • Phone: 757-314-7557
  • Fax:
Mailing address:
  • Phone: 757-873-8566
  • Fax: 757-595-1885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number0810006099
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810006099
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: