Healthcare Provider Details

I. General information

NPI: 1457171563
Provider Name (Legal Business Name): REWIRED CANVAS PSYCHOTHERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2024
Last Update Date: 03/27/2025
Certification Date: 03/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 COLONIAL AVE STE 12
NORFOLK VA
23517-1919
US

IV. Provider business mailing address

2200 COLONIAL AVE STE 12
NORFOLK VA
23517-1919
US

V. Phone/Fax

Practice location:
  • Phone: 757-589-3498
  • Fax:
Mailing address:
  • Phone: 757-589-3498
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number
License Number State

VIII. Authorized Official

Name: KERRY ANN KRUK-BORISOV
Title or Position: OWNER / MANAGER
Credential: LPC, ATR-BC, CSAC
Phone: 757-589-3498