Provider Demographics
NPI:1093867640
Name:BETAK, KIRSTEN MONTGOMERY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KIRSTEN
Middle Name:MONTGOMERY
Last Name:BETAK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5300 KINDLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-6611
Mailing Address - Country:US
Mailing Address - Phone:757-831-6246
Mailing Address - Fax:
Practice Address - Street 1:MEDICAL, PCU GHW BUSH CVN77, SUPSHIP NEWPORT NEWS
Practice Address - Street 2:4101 WASHINGTON AVE, BLDG 2
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23607
Practice Address - Country:US
Practice Address - Phone:757-534-1645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 19719103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical