Provider Demographics
NPI:1366762270
Name:BRENDA LEE DAVIS MA LPC LLC
Entity type:Organization
Organization Name:BRENDA LEE DAVIS MA LPC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC, RPT-S
Authorized Official - Phone:757-956-6100
Mailing Address - Street 1:2713 DEERFIELD CRES
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-2447
Mailing Address - Country:US
Mailing Address - Phone:757-956-6100
Mailing Address - Fax:757-956-6101
Practice Address - Street 1:3217 WESTERN BRANCH BLVD SUITE C
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321
Practice Address - Country:US
Practice Address - Phone:757-956-6100
Practice Address - Fax:757-956-6101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-03
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA701003883101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1144371857Medicaid