Provider Demographics
NPI:1316390420
Name:KRUK-BORISOV, KERRY ANN (LPC, ATR-BC, CSAC)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:ANN
Last Name:KRUK-BORISOV
Suffix:
Gender:F
Credentials:LPC, ATR-BC, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3140 HERBERT ST
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23513-2302
Mailing Address - Country:US
Mailing Address - Phone:757-589-3498
Mailing Address - Fax:
Practice Address - Street 1:2200 COLONIAL AVE STE 12
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23517-1919
Practice Address - Country:US
Practice Address - Phone:757-937-5780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-14
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0710102187101YA0400X
VA0701005892221700000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist