Provider Demographics
NPI:1083373740
Name:SUPREME HEALING PSYCHOLOGICAL SERVICES
Entity Type:Organization
Organization Name:SUPREME HEALING PSYCHOLOGICAL SERVICES
Other - Org Name:SUPREME HEALING PSYCHOLOGICAL SERVICES, PLLC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:CHIQUITA
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-933-5386
Mailing Address - Street 1:2101 EXECUTIVE DR STE 370
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-2404
Mailing Address - Country:US
Mailing Address - Phone:757-933-5386
Mailing Address - Fax:757-210-4197
Practice Address - Street 1:2101 EXECUTIVE DR STE 370
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-2404
Practice Address - Country:US
Practice Address - Phone:757-933-5386
Practice Address - Fax:757-210-4197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-09
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1467020339Medicaid