Healthcare Provider Details

I. General information

NPI: 1174029359
Provider Name (Legal Business Name): MYSPECTRUM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2018
Last Update Date: 06/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 N COURTHOUSE RD
NORTH CHESTERFIELD VA
23236-4045
US

IV. Provider business mailing address

707 N COURTHOUSE RD
NORTH CHESTERFIELD VA
23236-4045
US

V. Phone/Fax

Practice location:
  • Phone: 804-332-5696
  • Fax: 866-626-4469
Mailing address:
  • Phone: 804-332-5696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: SUZANNE CHRISTOPHER
Title or Position: DIRECTOR
Credential:
Phone: 804-332-5696