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General NPI Number Information
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NPI Number | 1457171563
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Entity Type | Organization
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Legal Business Name | REWIRED CANVAS PSYCHOTHERAPY LLC
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Dates
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Enumeration Date | 10/14/2024
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Last Update Date | 03/27/2025
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Provider Practice Location Address
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Address Line | 2200 COLONIAL AVE STE 12
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City | NORFOLK
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State | VA
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Zip | 23517-1919
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Country | US
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Telephone | 757-589-3498
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Fax |
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Provider Business Mailing Address
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Address Line | 2200 COLONIAL AVE STE 12
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City | NORFOLK
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State | VA
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Zip | 23517-1919
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Country | US
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Telephone | 757-589-3498
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Fax |
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Authorized Official
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Title or Position | OWNER / MANAGER
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Name | KERRY ANN KRUK-BORISOV
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Credential | LPC, ATR-BC, CSAC
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Telephone | 757-589-3498
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 221700000X
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Taxonomy Name | Art Therapist
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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 | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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