Healthcare Provider Details

I. General information

NPI: 1548090897
Provider Name (Legal Business Name): ELEMENTAL EXPRESSIVE ARTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2024
Last Update Date: 08/02/2024
Certification Date: 08/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 COUNTRYSIDE DR
RINGGOLD VA
24586-4417
US

IV. Provider business mailing address

8227 OLD OCEAN VIEW RD
NORFOLK VA
23518-2748
US

V. Phone/Fax

Practice location:
  • Phone: 757-524-1357
  • Fax: 757-296-0837
Mailing address:
  • Phone: 757-434-2644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: SARAH D PENSTON
Title or Position: OWNER
Credential: LPC, ATR-BC, EXAT
Phone: 757-524-1357