=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568136372
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRYAN JOSEPH TROTMAN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2021
-----------------------------------------------------
Last Update Date | 08/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5215 COLLEY AVE STE 122
-----------------------------------------------------
City | NORFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23508-2166
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-629-4352
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5215 COLLEY AVE STE 122
-----------------------------------------------------
City | NORFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23508-2166
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-629-4352
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 376905001
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------