Provider Demographics
NPI:1912363698
Name:KINGA GUDOR
Entity Type:Organization
Organization Name:KINGA GUDOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KINGA
Authorized Official - Middle Name:
Authorized Official - Last Name:GUDOR
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, PHD
Authorized Official - Phone:757-319-5416
Mailing Address - Street 1:1146 ROCKBRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23508-1418
Mailing Address - Country:US
Mailing Address - Phone:757-319-5416
Mailing Address - Fax:757-918-8760
Practice Address - Street 1:129 W VIRGINIA BEACH BLVD STE 204A
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23510-2030
Practice Address - Country:US
Practice Address - Phone:757-319-5416
Practice Address - Fax:757-918-8760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-11
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904007315101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1508187881Medicaid
VA1508187881Medicaid