Healthcare Provider Details

I. General information

NPI: 1083302269
Provider Name (Legal Business Name): NICHOLAS CLAY LRIC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2023
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4460 CORPORATION LN STE 300
VIRGINIA BEACH VA
23462-3150
US

IV. Provider business mailing address

4460 CORPORATION LN STE 300
VIRGINIA BEACH VA
23462-3150
US

V. Phone/Fax

Practice location:
  • Phone: 757-376-8167
  • Fax: 757-452-4447
Mailing address:
  • Phone: 757-376-8167
  • Fax: 757-452-4447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0704017103
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: