Healthcare Provider Details

I. General information

NPI: 1487130712
Provider Name (Legal Business Name): STACY CROSS LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2018
Last Update Date: 07/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17579 WARWICK BLVD
NEWPORT NEWS VA
23603-1343
US

IV. Provider business mailing address

404 MONUMENT CT
YORKTOWN VA
23693-4593
US

V. Phone/Fax

Practice location:
  • Phone: 757-888-0400
  • Fax:
Mailing address:
  • Phone: 757-865-0834
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0701007781
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: