Provider Demographics
NPI:1932816048
Name:STRANGE FRUIT PSYCHOTHERAPY LLC
Entity Type:Organization
Organization Name:STRANGE FRUIT PSYCHOTHERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:SHERVONNE
Authorized Official - Middle Name:EVETTE
Authorized Official - Last Name:BANKS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:757-240-7928
Mailing Address - Street 1:110 COLISEUM XING
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-5971
Mailing Address - Country:US
Mailing Address - Phone:757-240-7928
Mailing Address - Fax:
Practice Address - Street 1:1204 E PEMBROKE AVE
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23669-3226
Practice Address - Country:US
Practice Address - Phone:757-240-7928
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1033398003Medicaid