Provider Demographics
NPI:1811080047
Name:RESTORER OF BROKEN WALLS PC
Entity type:Organization
Organization Name:RESTORER OF BROKEN WALLS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:BOWERS
Authorized Official - Last Name:GRIZZARD
Authorized Official - Suffix:
Authorized Official - Credentials:LPC LMFT
Authorized Official - Phone:757-547-1811
Mailing Address - Street 1:644 INDEPENDENCE PARKWAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320
Mailing Address - Country:US
Mailing Address - Phone:757-547-1811
Mailing Address - Fax:757-547-1118
Practice Address - Street 1:644 INDEPENDENCE PARKWAY
Practice Address - Street 2:SUITE 200
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320
Practice Address - Country:US
Practice Address - Phone:757-547-1811
Practice Address - Fax:757-547-1118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004944402Medicaid