Provider Demographics
NPI:1710587795
Name:ROMM, MARY WILLOUGHBY (LPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:WILLOUGHBY
Last Name:ROMM
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1516 NEWMOOR DR
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER POINT
Mailing Address - State:VA
Mailing Address - Zip Code:23062-2601
Mailing Address - Country:US
Mailing Address - Phone:252-619-0887
Mailing Address - Fax:
Practice Address - Street 1:9228 GEORGE WASHINGTON MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:VA
Practice Address - Zip Code:23061-4162
Practice Address - Country:US
Practice Address - Phone:804-695-8120
Practice Address - Fax:804-695-8122
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701010029101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional