Taxonomy Codes
The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:
| No. |
Taxonomy Code |
Taxonomy Clasification |
Taxonomy Specialization |
License Number |
License State |
Primary |
| 1 | 103TC0700X | Psychologist | Clinical | 0810000976 | VIRGINIA | No |
| 2 | 103G00000X | Clinical Neuropsychologist | | 0810000976 | VIRGINIA | Yes |
Other Identifiers
The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.
| No. |
Other Provider Identifier |
Other Provider Identifier Type |
Other Provider Identifier State |
Other Provider Identifier Issuer |
| 1 | -006 | OTHER | VIRGINIA | TRICARE/CHAMPUS |
| 2 | 031141 | OTHER | VIRGINIA | VALUE OPTIONS |
| 3 | 081890 | OTHER | VIRGINIA | ANTHEM |
| 4 | 226230 | OTHER | VIRGINIA | MAGELLAN |
| 5 | PAR | OTHER | VIRGINIA | VIRGINIA PREMIER HEALTH |
| 6 | PAR | OTHER | VIRGINIA | CIGNA BEHAVIORAL HEALTH |
| 7 | 100024679 | OTHER | | APS |
| 8 | PAR | OTHER | VIRGINIA | CORVEL/CORCARE |
| 9 | PAR | OTHER | VIRGINIA | UNITED BEHAVIORAL HEALTH |
| 10 | 680004100 | MEDICARE PIN | VIRGINIA | |
| 11 | PAR | OTHER | VIRGINIA | AETNA |
| 12 | 87210 | OTHER | VIRGINIA | SENTARA/OPTIMA |
| 13 | PAR | OTHER | VIRGINIA | FIRST HEALTH COMMERCIAL |
| 14 | R61353 | MEDICARE UPIN | VIRGINIA | |
| 15 | 12835 | OTHER | NORTH CAROLINA | BC/BS |
| 16 | 680000230 | MEDICARE PIN | VIRGINIA | |
| 17 | PAR | OTHER | VIRGINIA | VIRGINIA HEALTH NETWORK |
| 18 | PAR | OTHER | VIRGINIA | MULTIPLAN |
| 19 | 133033 | OTHER | VIRGINIA | MANAGED HEALTH NETWORK |
| 20 | PAR | OTHER | VIRGINIA | USA MANAGED CARE |
| 21 | 215683 | OTHER | VIRGINIA | UHC/MAMSI |
| 22 | 007726759 | MEDICAID | VIRGINIA | |
