Provider Demographics
NPI:1548758998
Name:OVERBY, RENEE
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:OVERBY
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:PO BOX 346
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:VA
Mailing Address - Zip Code:24171-0346
Mailing Address - Country:US
Mailing Address - Phone:276-694-3163
Mailing Address - Fax:
Practice Address - Street 1:104 RUCKER STREET
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:VA
Practice Address - Zip Code:24171
Practice Address - Country:US
Practice Address - Phone:276-694-3163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-01
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAPGP-333485103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0813000236OtherVA DEPT OF HEALTH PROFESSIONALS
VAPGP-333485OtherVA DEPARTMENT OF EDUCATION