Healthcare Provider Details

I. General information

NPI: 1598438038
Provider Name (Legal Business Name): TEVYA ZUKOR PH.D., LCP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2021
Last Update Date: 07/30/2021
Certification Date: 07/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1809 GENTHER LN
FREDERICKSBURG VA
22401-5297
US

IV. Provider business mailing address

1809 GENTHER LN
FREDERICKSBURG VA
22401-5297
US

V. Phone/Fax

Practice location:
  • Phone: 703-283-6195
  • Fax:
Mailing address:
  • Phone: 703-283-6195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810003703
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: