Provider Demographics
NPI:1558935858
Name:GIRLS IN RECOVERY
Entity Type:Organization
Organization Name:GIRLS IN RECOVERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER AND CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHAZ
Authorized Official - Middle Name:LAMAR
Authorized Official - Last Name:CLYBURN
Authorized Official - Suffix:
Authorized Official - Credentials:APC
Authorized Official - Phone:757-892-0847
Mailing Address - Street 1:5321 JUSTIN CT APT 101
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-1352
Mailing Address - Country:US
Mailing Address - Phone:757-892-0847
Mailing Address - Fax:
Practice Address - Street 1:2920 N ARMISTEAD AVE
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-1640
Practice Address - Country:US
Practice Address - Phone:757-798-9094
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-20
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAA61620350OtherVIRGINIA ID CARD