Provider Demographics
NPI:1881171668
Name:FLY FAMILY THERAPY, INC.
Entity type:Organization
Organization Name:FLY FAMILY THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICIAN, SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:FLY
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:757-912-5359
Mailing Address - Street 1:718 J CLYDE MORRIS BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1540
Mailing Address - Country:US
Mailing Address - Phone:757-873-8566
Mailing Address - Fax:757-595-1885
Practice Address - Street 1:718 J CLYDE MORRIS BLVD STE D
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601-1540
Practice Address - Country:US
Practice Address - Phone:757-873-8566
Practice Address - Fax:757-595-1885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)