Healthcare Provider Details

I. General information

NPI: 1144047846
Provider Name (Legal Business Name): HAILEY WIERZBA NCSP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2024
Last Update Date: 09/24/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1033 POQUOSON AVE
POQUOSON VA
23662-1728
US

IV. Provider business mailing address

606 RIVER BEND CT APT 105
NEWPORT NEWS VA
23602-7053
US

V. Phone/Fax

Practice location:
  • Phone: 757-868-3050
  • Fax:
Mailing address:
  • Phone: 715-347-2404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number0608836
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: