Healthcare Provider Details

I. General information

NPI: 1801068606
Provider Name (Legal Business Name): FAIRFIELD PSYCHOLOGICAL ASSOC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2008
Last Update Date: 04/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5265 PROVIDENCE RD SUITE 500
VIRGINIA BEACH VA
23464-4206
US

IV. Provider business mailing address

5265 PROVIDENCE RD SUITE 500
VIRGINIA BEACH VA
23464-4206
US

V. Phone/Fax

Practice location:
  • Phone: 757-467-9500
  • Fax: 757-467-9560
Mailing address:
  • Phone: 757-467-9500
  • Fax: 757-467-9560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0904000552
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904000552
License Number StateVA

VIII. Authorized Official

Name: MR. GARY ROTFUS
Title or Position: PRESIDENT
Credential: LCSW
Phone: 757-467-9500