Healthcare Provider Details

I. General information

NPI: 1639560741
Provider Name (Legal Business Name): SPECTRUM TRANSFORMATION GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2015
Last Update Date: 03/24/2020
Certification Date: 03/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 STONEBRIDGE PLAZA AVE STE C
NORTH CHESTERFIELD VA
23225-6972
US

IV. Provider business mailing address

221 STONEBRIDGE PLAZA AVE STE C
NORTH CHESTERFIELD VA
23225-6972
US

V. Phone/Fax

Practice location:
  • Phone: 804-378-6141
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number161707010
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number StateVA

VIII. Authorized Official

Name: DR. CEDRIC A MOORE JR.
Title or Position: PRESIDENT AND CEO
Credential:
Phone: 804-378-6141