=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689616674
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EARL WAYNE FLORA PSYD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3305 POPLAR CREEK LN
-----------------------------------------------------
City | WILLIAMSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23188-1058
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-564-8522
-----------------------------------------------------
Fax | 757-566-0360
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 564
-----------------------------------------------------
City | NORGE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23127-0564
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-564-8522
-----------------------------------------------------
Fax | 757-566-0360
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 0810001797
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------