Healthcare Provider Details

I. General information

NPI: 1366565954
Provider Name (Legal Business Name): LYNESSA GLASS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 09/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4356 BONNEY RD BUILDING 1, SUITE 101
VIRGINIA BEACH VA
23452-1200
US

IV. Provider business mailing address

4356 BONNEY RD BUILDING 1, SUITE 101
VIRGINIA BEACH VA
23452-1200
US

V. Phone/Fax

Practice location:
  • Phone: 757-717-0605
  • Fax: 757-498-3311
Mailing address:
  • Phone: 757-717-0605
  • Fax: 757-498-3311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701002709
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0717000634
License Number StateVA

VIII. Authorized Official

Name: LYNESSA GLASS
Title or Position: DIRECTOR
Credential: LPC LMFT
Phone: 757-717-0605