=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639969116
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAIR WINDS THERAPY & CONSULTING SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2025
-----------------------------------------------------
Last Update Date | 05/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4007 LONG POINT BLVD
-----------------------------------------------------
City | PORTSMOUTH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-825-1650
-----------------------------------------------------
Fax | 757-276-6368
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 COLISEUM XING # 6068
-----------------------------------------------------
City | HAMPTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23666-5971
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-825-1650
-----------------------------------------------------
Fax | 757-276-6368
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ERICA RENEE EDGE
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 808-825-1650
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------