Healthcare Provider Details

I. General information

NPI: 1679185573
Provider Name (Legal Business Name): SHAPING YOUR FUTURE PSYCHIATRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2020
Last Update Date: 09/06/2024
Certification Date: 09/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3082 BRICKHOUSE CT STE B
VIRGINIA BEACH VA
23452-6859
US

IV. Provider business mailing address

4300 PORTSMOUTH BLVD UNIT 9183
CHESAPEAKE VA
23321-0607
US

V. Phone/Fax

Practice location:
  • Phone: 757-528-2850
  • Fax: 757-432-3159
Mailing address:
  • Phone: 757-528-2850
  • Fax: 757-432-3159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TRISHA NARDIA PARKER
Title or Position: CEO
Credential:
Phone: 757-528-2850