Healthcare Provider Details

I. General information

NPI: 1083010508
Provider Name (Legal Business Name): BRIAN S HAWKINS M.S.W
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MRS. TIJUANA N HAWKINS

II. Dates (important events)

Enumeration Date: 11/11/2014
Last Update Date: 11/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 BLAND ST
NORFOLK VA
23513-3386
US

IV. Provider business mailing address

1005 BLAND ST
NORFOLK VA
23513-3386
US

V. Phone/Fax

Practice location:
  • Phone: 757-572-7206
  • Fax:
Mailing address:
  • Phone: 757-572-7206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number2090-01-001
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: