Provider Demographics
NPI:1013552900
Name:ROCHA, EDGARDO ENRIQUE
Entity Type:Individual
Prefix:
First Name:EDGARDO
Middle Name:ENRIQUE
Last Name:ROCHA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 N LYNNHAVEN RD STE 118
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-7514
Mailing Address - Country:US
Mailing Address - Phone:757-456-0093
Mailing Address - Fax:
Practice Address - Street 1:228 N LYNNHAVEN RD STE 118
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-7514
Practice Address - Country:US
Practice Address - Phone:757-456-0093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-14
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0710103396101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)