Healthcare Provider Details

I. General information

NPI: 1598236465
Provider Name (Legal Business Name): DEMETRIUS R DONSEROUX LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2018
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5131 RIVER CLUB DR STE 200
SUFFOLK VA
23435-3837
US

IV. Provider business mailing address

5131 RIVER CLUB DR STE 200
SUFFOLK VA
23435-3837
US

V. Phone/Fax

Practice location:
  • Phone: 804-207-6737
  • Fax: 844-863-4621
Mailing address:
  • Phone: 804-207-6737
  • Fax: 844-863-4621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701012966
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC6501
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number65705
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMHCLH60509753
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: