Healthcare Provider Details

I. General information

NPI: 1407589559
Provider Name (Legal Business Name): ROXANA I AMUNDSEN RESIDENT IN COUNSELI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2022
Last Update Date: 05/09/2026
Certification Date: 05/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5832 HAWTHORN LN
WILLIAMSBURG VA
23185-8037
US

IV. Provider business mailing address

5832 HAWTHORN LN
WILLIAMSBURG VA
23185-8037
US

V. Phone/Fax

Practice location:
  • Phone: 757-725-6075
  • Fax:
Mailing address:
  • Phone: 757-725-6075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701016140
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: