| Restorer Of Broken Walls Pc | |
|
644 Independence Parkway Suite 200 Chesapeake VA 23320 | |
| (757) 547-1811 | |
| (757) 547-1118 |
| Full Name | Restorer Of Broken Walls Pc |
|---|---|
| Speciality | Counselor |
| Location | 644 Independence Parkway, Chesapeake, Virginia |
| Authorized Official Name and Position | Amanda Bowers Grizzard (PROGRAM DIRECTOR) |
| Authorized Official Contact | 7575471811 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Restorer Of Broken Walls Pc 644 Independence Parkway Suite 200 Chesapeake VA 23320 Ph: (757) 547-1811 | Restorer Of Broken Walls Pc 644 Independence Parkway Suite 200 Chesapeake VA 23320 Ph: (757) 547-1811 |
| NPI Number | 1811080047 |
|---|---|
| Provider Enumeration Date | 10/02/2006 |
| Last Update Date | 08/20/2024 |
| Certification Date | 07/31/2024 |
| Medicare PECOS PAC ID | 3779017603 |
|---|---|
| Medicare Enrollment ID | O20241114000753 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1811080047 | NPI | - | NPPES |
| 004944402 | Medicaid | VA |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101Y00000X | Counselor | (* (Not Available)) | Primary |
| Provider Name | Lisa Marie Willard |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1386717171 PECOS PAC ID: 1052846789 Enrollment ID: I20241119000651 |
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