Healthcare Provider Details

I. General information

NPI: 1114565413
Provider Name (Legal Business Name): AMANDA GROCUTT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2019
Last Update Date: 12/17/2019
Certification Date: 12/17/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7025 HARBOUR VIEW BLVD
SUFFOLK VA
23435-2761
US

IV. Provider business mailing address

317 WOODRUFF ST
SUFFOLK VA
23434-3452
US

V. Phone/Fax

Practice location:
  • Phone: 757-966-2805
  • Fax:
Mailing address:
  • Phone: 757-818-5051
  • 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:
Title or Position:
Credential:
Phone: