Healthcare Provider Details

I. General information

NPI: 1316016645
Provider Name (Legal Business Name): INDIAN RIVER PSYCHOLOGICAL ASSOCIATES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6477 COLLEGE PARK SQ SUITE 302
VIRGINIA BEACH VA
23464-3611
US

IV. Provider business mailing address

6477 COLLEGE PARK SQ SUITE 302
VIRGINIA BEACH VA
23464-3611
US

V. Phone/Fax

Practice location:
  • Phone: 757-424-0100
  • Fax: 757-424-5623
Mailing address:
  • Phone: 757-424-0100
  • Fax: 757-424-5623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MS. I. KIMBERLEE CHUCKER
Title or Position: PRESIDENT
Credential: LCSW
Phone: 757-424-0100