Healthcare Provider Details

I. General information

NPI: 1760371538
Provider Name (Legal Business Name): RENITHA IRVIN
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2025
Last Update Date: 06/28/2025
Certification Date: 06/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 EMANCIPATION DR
HAMPTON VA
23667-0001
US

IV. Provider business mailing address

1100 LAKEFRONT CMNS UNIT 229
NEWPORT NEWS VA
23606-3447
US

V. Phone/Fax

Practice location:
  • Phone: 757-722-9961
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberBBH-LCPC-LIC-8779
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: