Healthcare Provider Details

I. General information

NPI: 1417684515
Provider Name (Legal Business Name): BRENT ALAN SCHILDT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2022
Last Update Date: 09/09/2022
Certification Date: 09/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 W BANK ST
PETERSBURG VA
23803-3279
US

IV. Provider business mailing address

20 W BANK ST STE 3
PETERSBURG VA
23803-3279
US

V. Phone/Fax

Practice location:
  • Phone: 804-722-4299
  • Fax:
Mailing address:
  • Phone: 804-731-3539
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904014069
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: