Provider Demographics
NPI:1225889249
Name:EXPERIENCE RESTORATION
Entity Type:Organization
Organization Name:EXPERIENCE RESTORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LMHP-R
Authorized Official - Prefix:
Authorized Official - First Name:SHERRIE
Authorized Official - Middle Name:PATRICE
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-805-4813
Mailing Address - Street 1:2509 KENNON AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23513-4318
Mailing Address - Country:US
Mailing Address - Phone:757-805-4813
Mailing Address - Fax:
Practice Address - Street 1:2509 KENNON AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23513-4318
Practice Address - Country:US
Practice Address - Phone:757-805-4813
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-28
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health