Healthcare Provider Details

I. General information

NPI: 1710743521
Provider Name (Legal Business Name): BRIGHT SHADOWS TELEPSYCHIATRY SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2024
Last Update Date: 02/28/2024
Certification Date: 02/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4410 CLAIBORNE SQ E
HAMPTON VA
23666-2071
US

IV. Provider business mailing address

PO BOX 9244
HAMPTON VA
23670-0244
US

V. Phone/Fax

Practice location:
  • Phone: 252-751-5103
  • Fax: 252-751-5127
Mailing address:
  • Phone: 252-751-5103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: RONDESHYA KEYONNA COSBY
Title or Position: OWNER
Credential: NP
Phone: 252-751-5103