Healthcare Provider Details

I. General information

NPI: 1548395478
Provider Name (Legal Business Name): KRISTEN LEONARD FLY MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 12/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

718 J CLYDE MORRIS BLVD SUITE D
NEWPORT NEWS VA
23601-1540
US

IV. Provider business mailing address

718 J CLYDE MORRIS BLVD SUITE D
NEWPORT NEWS VA
23601-1540
US

V. Phone/Fax

Practice location:
  • Phone: 757-912-5359
  • Fax: 757-595-1885
Mailing address:
  • Phone: 757-912-5359
  • Fax: 757-595-1885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFTINTERN, IMF 49868
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0717001230
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: