Healthcare Provider Details

I. General information

NPI: 1154150647
Provider Name (Legal Business Name): BERNARD LAMONT HEYWARD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2024
Last Update Date: 07/31/2024
Certification Date: 07/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4324 FOX TROTTER DR
RICHMOND VA
23223-2349
US

IV. Provider business mailing address

4324 FOX TROTTER DR
RICHMOND VA
23223-2349
US

V. Phone/Fax

Practice location:
  • Phone: 804-317-7777
  • Fax:
Mailing address:
  • Phone: 804-317-7777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0704005770
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: