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General NPI Number Information
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NPI Number | 1346677820
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Entity Type | Organization
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Legal Business Name | PBP PSYCHOTHERAPY LTD
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Dates
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Enumeration Date | 09/30/2013
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Last Update Date | 09/30/2013
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Provider Practice Location Address
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Address Line | 110 MAYCOX AVE SUITE 3
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City | NORFOLK
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State | VA
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Zip | 23505-3433
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Country | US
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Telephone | 757-769-7040
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Fax | 757-769-7050
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Provider Business Mailing Address
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Address Line | 110 MAYCOX AVE SUITE 3
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City | NORFOLK
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State | VA
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Zip | 23505-3433
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Country | US
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Telephone | 757-769-7040
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Fax | 757-769-7050
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Authorized Official
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Title or Position | PRESIDENT
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Name | HOLLY TRACY
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Credential | MA
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Telephone | 757-769-7040
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 0701004033
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 0717001120
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License Number State | VA
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