Provider Demographics
NPI:1982776902
Name:PENINSULA PEDIATRIC PSYCHIATRY
Entity Type:Organization
Organization Name:PENINSULA PEDIATRIC PSYCHIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:B
Authorized Official - Last Name:TRICE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-593-6792
Mailing Address - Street 1:12350 JEFFERSON AVE
Mailing Address - Street 2:SUITE 190
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23602-6951
Mailing Address - Country:US
Mailing Address - Phone:757-881-9444
Mailing Address - Fax:
Practice Address - Street 1:12350 JEFFERSON AVE
Practice Address - Street 2:SUITE 190
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-6951
Practice Address - Country:US
Practice Address - Phone:757-881-9444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2008-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101230611103TC2200X
VA050920051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC09987Medicare PIN