Healthcare Provider Details

I. General information

NPI: 1336800093
Provider Name (Legal Business Name): TREVINA RENEE ANDERSON PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2022
Last Update Date: 01/05/2022
Certification Date: 01/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1503 SANTA ROSA RD RM 105
RICHMOND VA
23229-5105
US

IV. Provider business mailing address

7565 JACK PINE CT
QUINTON VA
23141-2689
US

V. Phone/Fax

Practice location:
  • Phone: 804-673-0100
  • Fax:
Mailing address:
  • Phone: 757-817-1869
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810007723
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: