Healthcare Provider Details

I. General information

NPI: 1043466394
Provider Name (Legal Business Name): CENTER FOR PSYCHOLOGICAL ASSESSMENT AND THERAPEUTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2008
Last Update Date: 08/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 VIRGINIA BEACH BLVD SUITE 511
VIRGINIA BEACH VA
23452-4445
US

IV. Provider business mailing address

3500 VIRGINIA BEACH BLVD SUITE 511
VIRGINIA BEACH VA
23452-4445
US

V. Phone/Fax

Practice location:
  • Phone: 757-340-1164
  • Fax: 757-340-1195
Mailing address:
  • Phone: 757-340-1164
  • Fax: 757-340-1195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number0810000350
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810000350
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number0810000350
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904005428
License Number StateVA

VIII. Authorized Official

Name: DR. GLENN REX MILLER
Title or Position: OWNER / PARTNER
Credential: PH.D
Phone: 757-340-1164