Healthcare Provider Details

I. General information

NPI: 1881171668
Provider Name (Legal Business Name): FLY FAMILY THERAPY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2018
Last Update Date: 07/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 757-873-8566
  • Fax: 757-595-1885
Mailing address:
  • Phone: 757-873-8566
  • Fax: 757-595-1885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateVA

VIII. Authorized Official

Name: KRISTEN L. FLY
Title or Position: CLINICIAN, SUPERVISOR
Credential: LMFT
Phone: 757-912-5359