Healthcare Provider Details

I. General information

NPI: 1538313069
Provider Name (Legal Business Name): CORINA H KOJACK LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2008
Last Update Date: 07/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4937 CLEVELAND ST
VIRGINIA BEACH VA
23462-5301
US

IV. Provider business mailing address

PO BOX 62018
VIRGINIA BEACH VA
23466-2018
US

V. Phone/Fax

Practice location:
  • Phone: 757-631-0099
  • Fax: 757-631-4971
Mailing address:
  • Phone: 757-631-0099
  • Fax: 757-631-4971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701004404
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: