| Strange Fruit Psychotherapy Llc | |
|
1204 E Pembroke Ave Hampton VA 23669-3226 | |
| (757) 240-7928 | |
| Not Available |
| Full Name | Strange Fruit Psychotherapy Llc |
|---|---|
| Speciality | Social Worker |
| Location | 1204 E Pembroke Ave, Hampton, Virginia |
| Authorized Official Name and Position | Shervonne Evette Banks (LICENSED CLINICAL SOCIAL WORKER) |
| Authorized Official Contact | 7572407928 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Strange Fruit Psychotherapy Llc 110 Coliseum Xing Hampton VA 23666-5971 Ph: (757) 240-7928 | Strange Fruit Psychotherapy Llc 1204 E Pembroke Ave Hampton VA 23669-3226 Ph: (757) 240-7928 |
| NPI Number | 1932816048 |
|---|---|
| Provider Enumeration Date | 10/31/2022 |
| Last Update Date | 10/31/2022 |
| Certification Date | 10/30/2022 |
| Medicare PECOS PAC ID | 9830557982 |
|---|---|
| Medicare Enrollment ID | O20230621002626 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1932816048 | NPI | - | NPPES |
| 1033398003 | Medicaid | VA |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1041C0700X | Social Worker - Clinical | (* (Not Available)) | Primary |
| Provider Name | Shervonne Evette Banks |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1033398003 PECOS PAC ID: 0749648897 Enrollment ID: I20230621002688 |
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