Healthcare Provider Details

I. General information

NPI: 1164582755
Provider Name (Legal Business Name): VIRGINIA ANN WYSE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 BREMO RD STE. 105
RICHMOND VA
23226-2440
US

IV. Provider business mailing address

2000 BREMO RD STE. 105
RICHMOND VA
23226-2440
US

V. Phone/Fax

Practice location:
  • Phone: 804-282-8332
  • Fax: 804-288-4558
Mailing address:
  • Phone: 804-282-8332
  • Fax: 804-288-4558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLPC0701004047
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: