Provider Demographics
NPI:1205261963
Name:PSYCHOLOGICAL SERVICES OF VIRGINIA
Entity type:Organization
Organization Name:PSYCHOLOGICAL SERVICES OF VIRGINIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LACONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:FANNING
Authorized Official - Suffix:
Authorized Official - Credentials:PSY-D
Authorized Official - Phone:757-235-3751
Mailing Address - Street 1:645 CHURCH ST STE 205
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23510-1712
Mailing Address - Country:US
Mailing Address - Phone:757-309-4688
Mailing Address - Fax:
Practice Address - Street 1:645 CHURCH ST STE 205
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23510-1712
Practice Address - Country:US
Practice Address - Phone:757-309-4688
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-12
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty