Provider Demographics
NPI:1801870043
Name:GRGURICH, ROSA CORMIER (LCSW, CSOTP)
Entity type:Individual
Prefix:
First Name:ROSA
Middle Name:CORMIER
Last Name:GRGURICH
Suffix:
Gender:F
Credentials:LCSW, CSOTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:289 INDEPENDENCE BLVD
Mailing Address - Street 2:PEMBROKE 3, STE 221
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-5493
Mailing Address - Country:US
Mailing Address - Phone:757-498-9320
Mailing Address - Fax:757-498-9321
Practice Address - Street 1:289 INDEPENDENCE BLVD
Practice Address - Street 2:PEMBROKE 3, STE 221
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-5493
Practice Address - Country:US
Practice Address - Phone:757-498-9320
Practice Address - Fax:757-498-9321
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040058271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA249880OtherCOMPSYCH
VA341848OtherTRICARE/MHN
VA156353OtherANTHEM
VAO81167MOtherSENTARA
VA341848OtherTRICARE/MHN