Healthcare Provider Details

I. General information

NPI: 1639012388
Provider Name (Legal Business Name): MANIFEST THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2026
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

618 BURTON ST
HAMPTON VA
23666-2164
US

IV. Provider business mailing address

618 BURTON ST
HAMPTON VA
23666-2164
US

V. Phone/Fax

Practice location:
  • Phone: 757-262-6784
  • Fax:
Mailing address:
  • Phone: 757-262-6784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name: MRS. TRINA MICHELLE LAVERTY
Title or Position: OWNER
Credential: LCSW
Phone: 757-262-6784