=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942991526
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIFFANY RACHEL MYRGA LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2023
-----------------------------------------------------
Last Update Date | 05/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20 W BANK ST
-----------------------------------------------------
City | PETERSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23803-3279
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-862-8000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7812 OLD GUILD RD
-----------------------------------------------------
City | NORTH CHESTERFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23237-1967
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-682-0721
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 0701009310
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------