Provider Demographics
NPI:1689858359
Name:WILLIAMSBURG PSYCHIATRIC MEDICINE
Entity Type:Organization
Organization Name:WILLIAMSBURG PSYCHIATRIC MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHUN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-253-7651
Mailing Address - Street 1:460 MCLAWS CIR
Mailing Address - Street 2:SUITE 130
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23185-5671
Mailing Address - Country:US
Mailing Address - Phone:757-253-7651
Mailing Address - Fax:757-253-7502
Practice Address - Street 1:460 MCLAWS CIR
Practice Address - Street 2:SUITE 130
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185-5671
Practice Address - Country:US
Practice Address - Phone:757-253-7651
Practice Address - Fax:757-253-7502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-18
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101222292103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VACO8829Medicare PIN