=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710460084
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HAWKINS PSYCHOLOGICAL SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2018
-----------------------------------------------------
Last Update Date | 05/10/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5272 LYNGATE CT STE 201
-----------------------------------------------------
City | BURKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22015-1688
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-718-3613
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5272 LYNGATE CT STE 201
-----------------------------------------------------
City | BURKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22015-1688
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-267-9482
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CLINICAL PSYCHOLOGIST
-----------------------------------------------------
Name | LESLIE ANN HAWKINS
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 757-718-3613
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------