Provider Demographics
NPI:1487188066
Name:STOUDMIRE, ANITA
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:
Last Name:STOUDMIRE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 JEFFERSON ST
Mailing Address - Street 2:SUITE 2C
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24504-1723
Mailing Address - Country:US
Mailing Address - Phone:804-554-0356
Mailing Address - Fax:
Practice Address - Street 1:5310 MARKEL RD
Practice Address - Street 2:SUITE 102
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-3030
Practice Address - Country:US
Practice Address - Phone:804-554-0356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-20
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701006971101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0701006971OtherLICENSE