Provider Demographics
NPI:1740408343
Name:ENTIN, ALAN DAVID (PHD)
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:DAVID
Last Name:ENTIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 MONUMENT AVE STE 510
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23220-7005
Mailing Address - Country:US
Mailing Address - Phone:804-359-0109
Mailing Address - Fax:
Practice Address - Street 1:1805 MONUMENT AVE STE 510
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23220-7005
Practice Address - Country:US
Practice Address - Phone:804-359-0109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810000606103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7712952Medicaid