Provider Demographics
NPI:1366453482
Name:LITTLE CREEK COUNSELING CTR
Entity Type:Organization
Organization Name:LITTLE CREEK COUNSELING CTR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:TAYLOR
Authorized Official - Last Name:MITCHUM
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD LCP
Authorized Official - Phone:757-628-8337
Mailing Address - Street 1:1709 COLLEY AVE
Mailing Address - Street 2:STE 311
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23517
Mailing Address - Country:US
Mailing Address - Phone:757-628-8337
Mailing Address - Fax:757-628-5911
Practice Address - Street 1:1709 COLLEY AVE
Practice Address - Street 2:STE 311
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23517
Practice Address - Country:US
Practice Address - Phone:757-628-8337
Practice Address - Fax:757-628-5911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810002730103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA140543OtherANTHEM BCBS
VA140543OtherANTHEM BCBS
VA=========001OtherTRICARE NORTH REGION
VA140543OtherANTHEM BCBS