Healthcare Provider Details

I. General information

NPI: 1982776902
Provider Name (Legal Business Name): PENINSULA PEDIATRIC PSYCHIATRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 06/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12350 JEFFERSON AVE SUITE 190
NEWPORT NEWS VA
23602-6951
US

IV. Provider business mailing address

12350 JEFFERSON AVE SUITE 190
NEWPORT NEWS VA
23602-6951
US

V. Phone/Fax

Practice location:
  • Phone: 757-881-9444
  • Fax:
Mailing address:
  • Phone: 757-881-9444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number0101230611
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number05092005
License Number StateVA

VIII. Authorized Official

Name: JULIE B TRICE
Title or Position: PRESIDENT
Credential: MD
Phone: 757-593-6792