Healthcare Provider Details

I. General information

NPI: 1386378057
Provider Name (Legal Business Name): NORTH SUFFOLK PSYCHIATRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2022
Last Update Date: 11/17/2023
Certification Date: 11/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3897 BRIDGE RD STE 104B
SUFFOLK VA
23435-1911
US

IV. Provider business mailing address

3897 BRIDGE RD STE 104
SUFFOLK VA
23435-1911
US

V. Phone/Fax

Practice location:
  • Phone: 757-758-6001
  • Fax:
Mailing address:
  • Phone: 757-758-6001
  • Fax: 757-758-6844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. KATLYN BROOKE TILLETT
Title or Position: MANAGING MEMBER
Credential: MSN, APRN, PMHNP-BC
Phone: 757-758-6001