Provider Demographics
NPI:1174029359
Name:MYSPECTRUM LLC
Entity Type:Organization
Organization Name:MYSPECTRUM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHRISTOPHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-332-5696
Mailing Address - Street 1:707 N COURTHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23236-4045
Mailing Address - Country:US
Mailing Address - Phone:804-332-5696
Mailing Address - Fax:
Practice Address - Street 1:707 N COURTHOUSE RD
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23236-4045
Practice Address - Country:US
Practice Address - Phone:804-332-5696
Practice Address - Fax:866-626-4469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-05
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1174029359Medicaid