Healthcare Provider Details

I. General information

NPI: 1235997164
Provider Name (Legal Business Name): BREAKTHROUGH GLOW, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2024
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 INVESTORS PL STE 106
VIRGINIA BEACH VA
23452-1166
US

IV. Provider business mailing address

PO BOX 4510
NORFOLK VA
23523-0510
US

V. Phone/Fax

Practice location:
  • Phone: 757-996-1837
  • Fax: 757-665-2855
Mailing address:
  • Phone: 757-996-1837
  • Fax: 757-665-2855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ALYCIA MARGARET ARCHER
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: MA LPC
Phone: 757-996-1837