Provider Demographics
NPI:1730637679
Name:WITHERSPOON, MARK ERIC
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ERIC
Last Name:WITHERSPOON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 INDEPENDENCE PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-5205
Mailing Address - Country:US
Mailing Address - Phone:757-420-0530
Mailing Address - Fax:757-420-0488
Practice Address - Street 1:640 INDEPENDENCE PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-5205
Practice Address - Country:US
Practice Address - Phone:757-420-0530
Practice Address - Fax:757-420-0488
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-20
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810003540103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical