MEDICARE: SPECTRUM PSYCHOLOGICAL AND NEUROTHERAPY PC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	103TC2200X	Clinical Child & Adolescent Psychologist
2	1041C0700X	Clinical Social Worker
3	103T00000X	Psychologist

General Provider Information

NPI Number	:	1407221716
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPECTRUM PSYCHOLOGICAL AND NEUROTHERAPY PC

Provider Business Mailing Address
First Line	:	4542 BONNEY RD STE B
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23462-3867
Country	:	US
Telephone Number	:	757-640-1882
Fax Number	:	757-640-0253

Provider Business Practice Location Address
First Line	:	4542 BONNEY RD STE B
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23462
Country	:	US
Telephone Number	:	757-640-1882
Fax Number	:	757-640-0253

Authorized Official
Title or Position	:	OWNER/CEO
Name	:	CARL RICHARD ELLIS
Credential	:	ED.D.
Telephone Number	:	757-640-1882

Provider Enumeration Date	:	12/11/2015
Last Update Date	:	08/15/2019

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