Healthcare Provider Details

I. General information

NPI: 1134727522
Provider Name (Legal Business Name): ASSESSMENT & COUNSELING OF WILLIAMSBURG PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2020
Last Update Date: 01/28/2021
Certification Date: 01/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 PROFESSIONAL DR STE C
WILLIAMSBURG VA
23185-3301
US

IV. Provider business mailing address

113 RUDDER CT
WILLIAMSBURG VA
23185-5288
US

V. Phone/Fax

Practice location:
  • Phone: 757-941-8182
  • Fax: 757-500-0134
Mailing address:
  • Phone: 757-284-4554
  • Fax: 757-808-5526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. BRENT CHRISTIAN PETERSON
Title or Position: PRESIDENT
Credential: PHD, LPC, ATR
Phone: 757-284-4554