MEDICARE: HAMPTON ROADS PSYCHOLOGICAL ASSOC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	0904000811	VA

General Provider Information

NPI Number	:	1003058033
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAMPTON ROADS PSYCHOLOGICAL ASSOC

Provider Business Mailing Address
First Line	:	3104 TYRE NECK RD
Second Line	:
City	:	PORTSMOUTH
State	:	VA
Zip	:	23703-4512
Country	:	US
Telephone Number	:	757-484-0616
Fax Number	:	757-484-0618

Provider Business Practice Location Address
First Line	:	3104 TYRE NECK RD
Second Line	:
City	:	PORTSMOUTH
State	:	VA
Zip	:	23703-4512
Country	:	US
Telephone Number	:	757-484-0616
Fax Number	:	757-484-0618

Authorized Official
Title or Position	:	PRESIDENT
Name	:	GREGORY M GRIFFIN
Credential	:	LCSW
Telephone Number	:	757-484-0616

Provider Enumeration Date	:	04/06/2009
Last Update Date	:	06/14/2010

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