Provider Demographics
NPI:1346677820
Name:PBP PSYCHOTHERAPY LTD
Entity Type:Organization
Organization Name:PBP PSYCHOTHERAPY LTD
Other - Org Name:PEACE BY PIECE PSYCHOTHERAPY LTD
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:TRACY
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:757-769-7040
Mailing Address - Street 1:110 MAYCOX AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23505-3433
Mailing Address - Country:US
Mailing Address - Phone:757-769-7040
Mailing Address - Fax:757-769-7050
Practice Address - Street 1:110 MAYCOX AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23505-3433
Practice Address - Country:US
Practice Address - Phone:757-769-7040
Practice Address - Fax:757-769-7050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-30
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701004033101YP2500X
VA0717001120106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010337411Medicaid