Healthcare Provider Details

I. General information

NPI: 1639601461
Provider Name (Legal Business Name): KRYSTAL NOWAK PSYCHOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2017
Last Update Date: 03/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4920 MILLRIDGE PKWY E SUITE 206
MIDLOTHIAN VA
23112-4857
US

IV. Provider business mailing address

4920 MILLRIDGE PKWY E SUITE 206
MIDLOTHIAN VA
23112-4857
US

V. Phone/Fax

Practice location:
  • Phone: 804-719-1955
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810005486
License Number StateVA

VIII. Authorized Official

Name: DR. KRYSTAL STUDIVANT NOWAK
Title or Position: LICENSED CLINICAL PSYCHOLOGIST
Credential: PSY.D.
Phone: 804-719-1955