Healthcare Provider Details

I. General information

NPI: 1447368139
Provider Name (Legal Business Name): LISA MYRA BERMAN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1503 SANTA ROSA RD
RICHMOND VA
23229
US

IV. Provider business mailing address

1503 SANTA ROSA RD
RICHMOND VA
23229
US

V. Phone/Fax

Practice location:
  • Phone: 804-282-9100
  • Fax: 804-282-3266
Mailing address:
  • Phone: 804-282-9100
  • Fax: 804-282-3266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810001667
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: