Provider Demographics
NPI:1316016645
Name:INDIAN RIVER PSYCHOLOGICAL ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:INDIAN RIVER PSYCHOLOGICAL ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:I.
Authorized Official - Middle Name:KIMBERLEE
Authorized Official - Last Name:CHUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:757-424-0100
Mailing Address - Street 1:6477 COLLEGE PARK SQ
Mailing Address - Street 2:SUITE 302
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-3611
Mailing Address - Country:US
Mailing Address - Phone:757-424-0100
Mailing Address - Fax:757-424-5623
Practice Address - Street 1:6477 COLLEGE PARK SQ
Practice Address - Street 2:SUITE 302
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-3611
Practice Address - Country:US
Practice Address - Phone:757-424-0100
Practice Address - Fax:757-424-5623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05887Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID CORP