Provider Demographics
NPI:1639560741
Name:SPECTRUM TRANSFORMATION GROUP, LLC
Entity Type:Organization
Organization Name:SPECTRUM TRANSFORMATION GROUP, LLC
Other - Org Name:SPECTRUM TRANSFORMATION GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CEDRIC
Authorized Official - Middle Name:A
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:804-378-6141
Mailing Address - Street 1:221 STONEBRIDGE PLAZA AVE STE C
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23225-6972
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:221 STONEBRIDGE PLAZA AVE STE C
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23225-6972
Practice Address - Country:US
Practice Address - Phone:804-378-6141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-11
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA161707010103K00000X, 103K00000X
VA103TB0200X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1174855985OtherNPI