Provider Demographics
NPI:1407221716
Name:SPECTRUM PSYCHOLOGICAL AND NEUROTHERAPY PC
Entity Type:Organization
Organization Name:SPECTRUM PSYCHOLOGICAL AND NEUROTHERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:757-640-1882
Mailing Address - Street 1:4542 BONNEY RD STE B
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-3867
Mailing Address - Country:US
Mailing Address - Phone:757-640-1882
Mailing Address - Fax:757-640-0253
Practice Address - Street 1:4542 BONNEY RD STE B
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462
Practice Address - Country:US
Practice Address - Phone:757-640-1882
Practice Address - Fax:757-640-0253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-11
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty