Provider Demographics
NPI:1013498757
Name:MASTERSON PSYCHOTHERAPY, LLC
Entity Type:Organization
Organization Name:MASTERSON PSYCHOTHERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MASTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:757-237-2906
Mailing Address - Street 1:4445 CORPORATION LN STE 213
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-3262
Mailing Address - Country:US
Mailing Address - Phone:757-237-2906
Mailing Address - Fax:757-216-9655
Practice Address - Street 1:4445 CORPORATION LN STE 213
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-3262
Practice Address - Country:US
Practice Address - Phone:757-237-2906
Practice Address - Fax:757-216-9655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-21
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904006823261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1851552491Medicaid