Healthcare Provider Details

I. General information

NPI: 1316947328
Provider Name (Legal Business Name): PSYCHOTHERAPY RESOURCES OF NORFOLK LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1709 COLLEY AVE SUITE 312
NORFOLK VA
23517-1675
US

IV. Provider business mailing address

1709 COLLEY AVE SUITE 312
NORFOLK VA
23517-1675
US

V. Phone/Fax

Practice location:
  • Phone: 757-640-0400
  • Fax: 757-640-0497
Mailing address:
  • Phone: 757-640-0400
  • Fax: 757-640-0497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4274
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4274
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4274
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904000234
License Number StateVA

VIII. Authorized Official

Name: BETTY ALEXANDRA KEDROCK
Title or Position: PRESIDENT
Credential: LCSW
Phone: 757-640-0400