Healthcare Provider Details

I. General information

NPI: 1508409152
Provider Name (Legal Business Name): OBSIDIAN COUNSELING AND WELLNESS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2019
Last Update Date: 04/02/2020
Certification Date: 04/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6387 CENTER DR STE 19
NORFOLK VA
23502-4109
US

IV. Provider business mailing address

857 GEORGE WASHINGTON HWY N UNIT 6991
CHESAPEAKE VA
23323-1362
US

V. Phone/Fax

Practice location:
  • Phone: 757-453-3051
  • Fax:
Mailing address:
  • Phone: 757-453-3051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: NATASHA BECKUM
Title or Position: CHIEF EXECUTIVE OFFICER/LPC
Credential: LPC
Phone: 757-453-3051