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General NPI Number Information
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NPI Number | 1790038602
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Entity Type | Organization
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Legal Business Name | FORKIDS,INC.
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Dates
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Enumeration Date | 10/17/2012
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Last Update Date | 10/17/2012
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Provider Practice Location Address
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Address Line | 131 D VIEW AVE
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City | NORFOLK
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State | VA
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Zip | 23503-2901
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Country | US
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Telephone | 757-622-6400
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Fax | 757-257-0212
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Provider Business Mailing Address
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Address Line | 4200 COLLEY AVE
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City | NORFOLK
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State | VA
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Zip | 23508-2508
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Country | US
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Telephone | 757-622-6400
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Fax | 757-257-0212
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Authorized Official
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Title or Position | MANAGER OF CLINICAL SERVICES
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Name | KATE HERMANSON
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Credential | LPC
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Telephone | 757-622-6400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 0701004678
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License Number State | VA
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