Provider Demographics
NPI:1609807304
Name:THE HEALING FOUNTAIN, LLC
Entity Type:Organization
Organization Name:THE HEALING FOUNTAIN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:J
Authorized Official - Last Name:HOPKINS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:757-486-1807
Mailing Address - Street 1:762 INDEPENDENCE BLVD
Mailing Address - Street 2:SUITE 100C
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-6200
Mailing Address - Country:US
Mailing Address - Phone:757-486-1807
Mailing Address - Fax:757-486-0901
Practice Address - Street 1:762 INDEPENDENCE BLVD
Practice Address - Street 2:SUITE 100C
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-6200
Practice Address - Country:US
Practice Address - Phone:757-486-1807
Practice Address - Fax:757-486-0901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040037261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA087506MOtherOPTIMA
VA008931909Medicaid
VA89750OtherBC/BS
VA087506MOtherOPTIMA
VA008931909Medicaid