=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396008264
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PENINSULA COUNSELING CENTER OF VIRGINIA, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2012
-----------------------------------------------------
Last Update Date | 06/16/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 751 THIMBLE SHOALS BLVD D-3
-----------------------------------------------------
City | NEWPORT NEWS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23606-3563
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-810-5380
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 751 THIMBLE SHOALS BLVD D-3
-----------------------------------------------------
City | NEWPORT NEWS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23606-3563
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-810-5380
-----------------------------------------------------
Fax | 757-886-0262
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | DONNA KAY GRISET
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 757-810-5380
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 0701003308
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------