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General NPI Number Information
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NPI Number | 1407221716
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Entity Type | Organization
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Legal Business Name | SPECTRUM PSYCHOLOGICAL AND NEUROTHERAPY PC
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Dates
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Enumeration Date | 12/11/2015
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Last Update Date | 08/15/2019
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Provider Practice Location Address
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Address Line | 4542 BONNEY RD STE B
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City | VIRGINIA BEACH
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State | VA
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Zip | 23462
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Country | US
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Telephone | 757-640-1882
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Fax | 757-640-0253
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Provider Business Mailing Address
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Address Line | 4542 BONNEY RD STE B
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City | VIRGINIA BEACH
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State | VA
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Zip | 23462-3867
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Country | US
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Telephone | 757-640-1882
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Fax | 757-640-0253
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Authorized Official
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Title or Position | OWNER/CEO
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Name | CARL RICHARD ELLIS
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Credential | ED.D.
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Telephone | 757-640-1882
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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