Provider Demographics
NPI:1033539820
Name:NOTORIETY, LLC
Entity Type:Organization
Organization Name:NOTORIETY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRINA
Authorized Official - Middle Name:BERNNADETTE
Authorized Official - Last Name:DAVIS-FORTUNE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:804-901-6928
Mailing Address - Street 1:715 E 4TH ST # F28
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23224-5559
Mailing Address - Country:US
Mailing Address - Phone:804-901-6928
Mailing Address - Fax:804-414-7733
Practice Address - Street 1:715 E 4TH ST # F28
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23224-5559
Practice Address - Country:US
Practice Address - Phone:804-901-6928
Practice Address - Fax:804-414-7733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-21
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040082811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1174959969Medicaid