MEDICARE: NOTORIETY, LLC

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	0904008281	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1033539820
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NOTORIETY, LLC

Provider Business Mailing Address
First Line	:	715 E 4TH ST # F28
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23224-5559
Country	:	US
Telephone Number	:	804-901-6928
Fax Number	:	804-414-7733

Provider Business Practice Location Address
First Line	:	715 E 4TH ST # F28
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23224-5559
Country	:	US
Telephone Number	:	804-901-6928
Fax Number	:	804-414-7733

Authorized Official
Title or Position	:	OWNER
Name	:	TRINA BERNNADETTE DAVIS-FORTUNE
Credential	:	LCSW
Telephone Number	:	804-901-6928

Provider Enumeration Date	:	04/21/2014
Last Update Date	:	04/21/2014

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Directions to “NOTORIETY, LLC ” Practice Location

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