Healthcare Provider Details

I. General information

NPI: 1881518645
Provider Name (Legal Business Name): OLD DOMINION UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2026
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1074 47TH ST
NORFOLK VA
23508-1910
US

IV. Provider business mailing address

1074 47TH ST
NORFOLK VA
23508-1910
US

V. Phone/Fax

Practice location:
  • Phone: 757-683-6988
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: PETER ANTHONY MOLLICA
Title or Position: HS MEDICAL DIAGNOSTIC AND TRANSLATI
Credential:
Phone: 757-683-3459