Healthcare Provider Details

I. General information

NPI: 1407221716
Provider Name (Legal Business Name): SPECTRUM PSYCHOLOGICAL AND NEUROTHERAPY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2015
Last Update Date: 08/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4542 BONNEY RD STE B
VIRGINIA BEACH VA
23462
US

IV. Provider business mailing address

4542 BONNEY RD STE B
VIRGINIA BEACH VA
23462-3867
US

V. Phone/Fax

Practice location:
  • Phone: 757-640-1882
  • Fax: 757-640-0253
Mailing address:
  • Phone: 757-640-1882
  • Fax: 757-640-0253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: CARL RICHARD ELLIS
Title or Position: OWNER/CEO
Credential: ED.D.
Phone: 757-640-1882