Provider Demographics
NPI:1124134150
Name:WOODBURY, PETER T (LCSW)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:T
Last Name:WOODBURY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:923 FIRST COLONIAL RD
Mailing Address - Street 2:SUITE 1809
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-3182
Mailing Address - Country:US
Mailing Address - Phone:475-737-0008
Mailing Address - Fax:757-437-0019
Practice Address - Street 1:923 FIRST COLONIAL RD
Practice Address - Street 2:SUITE 1809
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-3182
Practice Address - Country:US
Practice Address - Phone:475-737-0008
Practice Address - Fax:757-437-0019
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040063551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical