Healthcare Provider Details

I. General information

NPI: 1548890262
Provider Name (Legal Business Name): THERESA BUNDY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2020
Last Update Date: 01/22/2020
Certification Date: 01/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7113 THREE CHOPT RD
RICHMOND VA
23226-3643
US

IV. Provider business mailing address

2632 CENTRAL AVE
RICHMOND VA
23225-2062
US

V. Phone/Fax

Practice location:
  • Phone: 804-562-9997
  • Fax: 804-562-9742
Mailing address:
  • Phone: 804-363-6606
  • Fax: 866-273-7097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number0701008882
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number0701008882
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: