Healthcare Provider Details

I. General information

NPI: 1366562092
Provider Name (Legal Business Name): MR. EHREN MICHAEL FLYNN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 05/05/2022
Certification Date: 05/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5102 W VILLAGE GREEN DR STE 102
MIDLOTHIAN VA
23112-4876
US

IV. Provider business mailing address

2512 TANGLEBROOK RD
MIDLOTHIAN VA
23112-4049
US

V. Phone/Fax

Practice location:
  • Phone: 804-743-0960
  • Fax:
Mailing address:
  • Phone: 804-971-3964
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904008540
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: