Provider Demographics
NPI:1861829764
Name:ETHOS LEADERSHIP PROJECT, LLC
Entity Type:Organization
Organization Name:ETHOS LEADERSHIP PROJECT, LLC
Other - Org Name:THE ETHOS LEADERSHIP GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:M
Authorized Official - Last Name:GOMES
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, PMHNP-BC
Authorized Official - Phone:757-251-6367
Mailing Address - Street 1:1322 LASALLE AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23669-3810
Mailing Address - Country:US
Mailing Address - Phone:757-251-6367
Mailing Address - Fax:
Practice Address - Street 1:1322 LASALLE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23669-3810
Practice Address - Country:US
Practice Address - Phone:757-251-6367
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-09
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024170504363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty