Provider Demographics
NPI:1497760193
Name:THE VIRGINIA INSTITUTE FOR MARITAL & FAMILY THERAPY
Entity Type:Organization
Organization Name:THE VIRGINIA INSTITUTE FOR MARITAL & FAMILY THERAPY
Other - Org Name:THE VIRGINIA INSTITUTE FOR SYSTEMIC TREATMENT
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:SANFORD
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT LPC CSAC NCC
Authorized Official - Phone:804-365-8555
Mailing Address - Street 1:13911 ST FRANCIS BLVD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23114
Mailing Address - Country:US
Mailing Address - Phone:804-365-8555
Mailing Address - Fax:804-365-8575
Practice Address - Street 1:13911 ST FRANCIS BLVD
Practice Address - Street 2:SUITE 106
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23114
Practice Address - Country:US
Practice Address - Phone:804-365-8555
Practice Address - Fax:804-365-8575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0717000980106H00000X
VA72405001251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty