Provider Demographics
NPI:1447741277
Name:HARDY, REBECCA J (EDS)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:J
Last Name:HARDY
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2208 N LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-2018
Mailing Address - Country:US
Mailing Address - Phone:757-632-8176
Mailing Address - Fax:
Practice Address - Street 1:1413 LASKIN RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451-6007
Practice Address - Country:US
Practice Address - Phone:757-263-2400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-29
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0813000591103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0813000591OtherCOMMONWEALTH OF VIRGINIA DEPARTMENT OF HEALTH PROFESSIONS