Healthcare Provider Details

I. General information

NPI: 1053109694
Provider Name (Legal Business Name): ETHEREAL TOUCH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2025
Last Update Date: 10/15/2025
Certification Date: 10/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 TIDEWATER DRIVE SUITE 2525
NORFOLK VA
23510
US

IV. Provider business mailing address

1832 KEMPSVILLE RD SUITE 112 #22
VIRGINIA BEACH VA
23464-1886
US

V. Phone/Fax

Practice location:
  • Phone: 757-335-6176
  • Fax:
Mailing address:
  • Phone: 757-335-6176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State

VIII. Authorized Official

Name: LYNESHA WOMBLE
Title or Position: LPC
Credential: LPC
Phone: 434-483-1081