MEDICARE: MR. LEVESTER WAYNE STOCKDALE LCSW

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	0904002029	VA

General Provider Information

NPI Number	:	1992821029
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LEVESTER WAYNE STOCKDALE LCSW

Provider Business Mailing Address
First Line	:	3762 CHIMNEY CREEK DR
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23462-6821
Country	:	US
Telephone Number	:	757-498-3557
Fax Number	:	757-616-0738

Provider Business Practice Location Address
First Line	:	850 TIDEWATER DR
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23504-3300
Country	:	US
Telephone Number	:	757-616-0736
Fax Number	:	757-616-0738

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/21/2007
Last Update Date	:	07/08/2007

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