1932816048 NPI number — STRANGE FRUIT PSYCHOTHERAPY LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932816048 NPI number — STRANGE FRUIT PSYCHOTHERAPY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STRANGE FRUIT PSYCHOTHERAPY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1932816048
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/31/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
110 COLISEUM XING
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAMPTON
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23666-5971
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-240-7928
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1204 E PEMBROKE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAMPTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23669-3226
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-240-7928
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/31/2022

Additional Information

Authorized Official

Authorized Official Last Name:
BANKS
Authorized Official First Name:
SHERVONNE
Authorized Official Middle Name:
EVETTE
Authorized Official Title or Position:
LICENSED CLINICAL SOCIAL WORKER
Authorized Official Telephone Number:
757-240-7928

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1033398003 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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