Provider Demographics
NPI:1174838320
Name:ROBERTS, MARY R (LPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:R
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:RITCHIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23501-0936
Mailing Address - Country:US
Mailing Address - Phone:757-446-5888
Mailing Address - Fax:757-446-5918
Practice Address - Street 1:825 FAIRFAX AVE STE 710
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1914
Practice Address - Country:US
Practice Address - Phone:757-446-5888
Practice Address - Fax:757-446-5918
Is Sole Proprietor?:No
Enumeration Date:2010-08-12
Last Update Date:2018-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701003086101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA089353OtherSENTARA
VA287533OtherANTHEM HMO HEALTHKEEPERS MENTAL HEALTH PROVIDER NETWORK
VA461637OtherANTHEM
VA4945425Medicaid