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General NPI Number Information
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NPI Number | 1437590601
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Entity Type | Organization
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Legal Business Name | PHOENIX MENTAL HEALTH LLC
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Dates
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Enumeration Date | 07/16/2013
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Last Update Date | 07/22/2013
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Provider Practice Location Address
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Address Line | 100 S BOGGS AVE
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City | VIRGINIA BEACH
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State | VA
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Zip | 23452-1705
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Country | US
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Telephone | 757-453-4017
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Fax |
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Provider Business Mailing Address
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Address Line | 810 KEMPSVILLE RD STE 6
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City | VIRGINIA BEACH
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State | VA
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Zip | 23464-2723
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Country | US
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Telephone | 757-453-4017
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Fax |
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Authorized Official
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Title or Position | LPC
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Name | DR. RICHARD M MASON JR.
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Credential | PHD, LPC, ACS
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Telephone | 757-453-4017
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305S00000X
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Taxonomy Name | Point of Service
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License Number | 0701003229
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License Number State | VA
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