Provider Demographics
NPI:1720558075
Name:FLY, DAVID RICHARD (PHD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:RICHARD
Last Name:FLY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:718 J CLYDE MORRIS BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1540
Mailing Address - Country:US
Mailing Address - Phone:757-873-8566
Mailing Address - Fax:757-595-1885
Practice Address - Street 1:718 J CLYDE MORRIS BLVD STE D
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601-1540
Practice Address - Country:US
Practice Address - Phone:757-873-8566
Practice Address - Fax:757-595-1885
Is Sole Proprietor?:No
Enumeration Date:2018-11-29
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810006099103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical