Healthcare Provider Details

I. General information

NPI: 1346677820
Provider Name (Legal Business Name): PBP PSYCHOTHERAPY LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2013
Last Update Date: 09/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 MAYCOX AVE SUITE 3
NORFOLK VA
23505-3433
US

IV. Provider business mailing address

110 MAYCOX AVE SUITE 3
NORFOLK VA
23505-3433
US

V. Phone/Fax

Practice location:
  • Phone: 757-769-7040
  • Fax: 757-769-7050
Mailing address:
  • Phone: 757-769-7040
  • Fax: 757-769-7050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701004033
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0717001120
License Number StateVA

VIII. Authorized Official

Name: HOLLY TRACY
Title or Position: PRESIDENT
Credential: MA
Phone: 757-769-7040