Healthcare Provider Details

I. General information

NPI: 1508187881
Provider Name (Legal Business Name): KINGA GUDOR MSW, LCSW, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2010
Last Update Date: 09/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 W VIRGINIA BEACH BLVD STE 204A
NORFOLK VA
23510-2030
US

IV. Provider business mailing address

1146 ROCKBRIDGE AVE
NORFOLK VA
23508-1418
US

V. Phone/Fax

Practice location:
  • Phone: 757-319-5416
  • Fax: 757-918-8760
Mailing address:
  • Phone: 757-319-5416
  • Fax: 757-918-8760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904007315
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: