Provider Demographics
NPI:1972016376
Name:BEACON PSYCHOTHERAPY SERVICES, LLC
Entity Type:Organization
Organization Name:BEACON PSYCHOTHERAPY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:FREDRIC
Authorized Official - Middle Name:HARVEY
Authorized Official - Last Name:BRICKA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, CSAC
Authorized Official - Phone:757-818-4542
Mailing Address - Street 1:3640 S PLAZA TRL STE 103D
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-3363
Mailing Address - Country:US
Mailing Address - Phone:757-818-4542
Mailing Address - Fax:757-299-3031
Practice Address - Street 1:3640 S PLAZA TRL STE 103D
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-3363
Practice Address - Country:US
Practice Address - Phone:757-818-4542
Practice Address - Fax:757-299-3031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-08
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010142768Medicaid